Systematic Review of Aac on Non Vernal Children
Rev Paul Pediatr. 2022; twoscore: e2020158.
Language: English language | Portuguese
Update virtually "minimally verbal" children with autism spectrum disorder
Atualização sobre crianças "minimamente verbais" com transtorno do espectro do autismo
Annio Posar
aIRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Infantile, Bologna, Italia.
Paola Visconti
aIRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Infantile, Bologna, Italian republic.
Received 2020 May 23; Accepted 2020 Sep 12.
Abstract
Objective:
To review clinical and neurobiological features of minimally verbal children with autism spectrum disorder.
Information source:
We carried out a narrative review using the PubMed database. We considered the following search terms combined through the Boolean operator "AND": "autism spectrum disorder"; "minimally verbal."
Information synthesis:
To appointment, at that place is no shared definition of minimally verbal children with autism spectrum disorder. The heterogeneity in intellectual functioning and in linguistic abilities amid these individuals suggests in that location is no single mechanism underlying their difficulties in learning to speak. However, the reasons why these children practice not speak and the biological markers that can identify them are still unknown. Linguistic communication impairment in these children can lead to several unfavorable consequences, including behavior issues (such every bit cocky-aggression, hetero-aggression, and property destruction), poorer daily living and social skills. Psychiatric comorbidities (including attention deficit/hyperactivity disorder, specific phobias, and compulsions) consist in a serious problem related to the lack of exact language in individuals with autism spectrum disorder. Although in the literature in that location are very few show-based results, several findings propose that an alternative and augmentative communication intervention, creating an extra-verbal advice channel, may be effective in these individuals.
Conclusions:
The verbal definition, clinical characteristics, associated disorders, etiology, and treatment of minimally exact subjects with autism spectrum disorder must still be further studied and understood.
Keywords: Autism spectrum disorder, Children, Language, Advice, Beliefs
RESUMO
Objetivo:
Revisar as características clínicas e neurobiológicas de crianças minimamente verbais com transtorno do espectro do autismo.
Fontes de dados:
Realizamos uma revisão narrativa utilizando o banco de dados PubMed. Foram considerados os seguintes termos de pesquisa combinados através do operador booleano "AND": "transtorno do espectro autista"; "Minimamente verbal".
Síntese dos dados:
Até o momento, não existe uma definição compartilhada de crianças minimamente verbais com transtorno do espectro do autismo. A heterogeneidade no funcionamento intelectual due east nas habilidades linguísticas entre esses indivíduos sugere que não há um mecanismo único subjacente às dificuldades de aprender a falar. No entanto, não sabemos bone motivos pelos quais essas crianças não falam, nem os marcadores biológicos que podem identificá-las. O comprometimento da linguagem nessas crianças pode levar a várias conseqüências desfavoráveis, incluindo problemas de comportamento (como auto-agressão, hetero-agressão e destruição de propriedades), pior qualidade de vida diária e habilidades sociais. A comorbidade psiquiátrica (incluindo transtorno de déficit de atenção/hiperatividade, fobias específicas, compulsões) é um problema grave relacionado à falta de linguagem verbal em indivíduos com transtorno do espectro do autismo. Embora na literatura existam muito poucos resultados baseados em evidências, vários achados sugerem que uma intervenção de comunicação alternativa e aumentativa, criando um culvert de comunicação extra-verbal, pode ser eficaz nesses indivíduos.
Conclusões:
Muito ainda precisa ser entendido sobre a definição exata, características clínicas, distúrbios associados, etiologia e tratamento de indivíduos minimamente verbais com transtorno exercise espectro practise autismo.
Palavras-chave: Transtorno do espectro autista, Crianças, Língua, Comunicação, Comportamento
INTRODUCTION
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-five),1 the criteria for autism spectrum disorder (ASD) diagnosis include the presence of persisting deficits of social communication and social interaction in different contexts as well as patterns of restricted and repetitive behaviors, interests or activities. ASD symptoms often appear in early childhood, but may fully manifest later, and they significantly impact the daily functioning of affected individuals. I aspect that must not be overlooked is that symptoms are not explained past the global developmental delay or by the intellectual inability that are often associated with ASD. Compared with its previous versions,2 the DSM-five proposed more specific diagnostic criteria for ASD, and language disorders are no longer considered equally a central feature of ASD.ane However, a variable degree of exact linguistic communication impairment is usually presented by ASD individuals. At first, nearly 25–thirty% of ASD children practise not develop any functional verbal language or stay minimally verbal (MV).3 – 5 That is, from an epidemiological signal of view, in the general population the number of nonverbal or MV ASD children is non negligible at all. In the U.s.a. of America, ASD prevalence at the age of 8 years, according to DSM-5 criteria,i is now xviii.5 per one,000 children, that is, ane child out of 54 has an ASD.6 Therefore, it could exist assumed that, at least in the U.s.a., at the age of 8 years, about 5 out of ane,000 children (i.e., 1 out of 200) accept an ASD and, at the same time, are nonverbal or MV. Consequently, the trouble of MV children with ASD is very of import likewise because of its considerable social and welfare costs. Nevertheless, there is no exact and broad definition of MV in the field of ASD yet; in this review, the "MV" abbreviation volition besides be used to refer to ASD children with completely absent-minded speech.
METHOD
A narrative review using the PubMed database (Us National Library of Medicine) was carried out. The following search terms combined through the Boolean operator "AND" were considered: "autism spectrum disorder"; and "minimally verbal." Initially, 85 studies were selected and read. And then, studies that only marginally addressed the topic of ASD children who are MV were excluded as well every bit those addressing very specific aspects of this topic. Both authors of the present review participated in this selection. Thus, 17 studies were finally selected, comprising reviews (either systematic or not-systematic) and original articles written in English, performed anywhere, addressing the subject of definition, diagnosis, neurobiology, clinical findings, associated bug, prognosis, and treatment of ASD individuals who are MV (Effigy i). Additional relevant bibliographic references related to the topic were likewise considered; such references take been mentioned in the studies selected by PubMed or have somehow been acknowledged by the authors. The references included in this review were analyzed in particular past A.P.
Article selection flow chart.
RESULTS
Language and autism spectrum disorder
The impairment of early verbal communication is usually one of the first concerns reported by parents of ASD children.7 In these individuals, the severity and the characteristics of language harm profoundly varies depending on the instance. Strictly speaking, nonverbal children are non MV children; simply these 2 expressions, both in clinical practice and in literature, are actually and often interchangeably used.
Most ASD children develop verbal language in the preschool period, but its progress can occur later as well.eight , 9 Their language, however, presents a series of irregularities, including in prosody, pragmatics, and semantics, which arrive very peculiar, only will not exist covered in this article. Information technology is worth mentioning that the trouble of advice in individuals with ASD is not limited to verbal language, but also involves other areas of communication including mimicry and gestures. Regardless of ASD, the severe or relative lack of linguistic communication is a negative gene for intellectual development, as indirectly suggested several decades ago by the pioneering piece of work of Lev Vygotskji, who studied how language acquisition can influence the cognitive development of children.10 However, according to Munson et al.,eleven this does not mean that MV subjects ever have a relevant deficit of nonverbal intellectual functioning, as shown past the results obtained by many of these individuals when assessed through standardized tests for intelligence quotient (IQ) bypassing the verbal channel such every bit the Leiter International Performance Calibration.12 On the other paw, while some MV children with ASD have low expressive and receptive verbal skills, others take good (or relatively skilful) receptive abilities, which somehow seem to be related to their nonverbal skills,thirteen though beingness difficult to evaluate in these children.14 This heterogeneity in intellectual performance and linguistic abilities betwixt MV individuals with ASD suggests at that place is no single mechanism underlying their difficulties in learning to speak.3
Language harm in ASD children, and particularly in MV ones, can lead to various unfavorable consequences, including behavior problems (such equally self-aggression, hetero-aggression, and property destruction),fifteen – 17 poorer daily living and social skills.eighteen Sometimes, beliefs problems can become and so severe and hard to manage, and they start being called "challenging behaviors."19 Equally expected, these individuals are affected past negative repercussions regarding the school surroundings, work opportunities, and contained life, and lower quality of life and reduced opportunities for participation in the customs have been reported for MV individuals.20 , 21
Psychiatric comorbidities consist in a serious problem related to the lack of exact language in ASD individuals. Plesa Skwerer et al. studied 65 MV children and adolescents with ASD. They found a wide range of concomitant psychopathological disorders (including attending-deficit/hyperactivity disorder [ADHD], specific phobias, and compulsions) and a loftier degree of maladaptive behavior, non direct due to the severity of autistic symptoms, intellectual disabilities, or limitations in adaptive performance.22
Williams et al. have a different perspective; the authors compared individuals with ASD hospitalized in a psychiatric establishment (historic period range: 4–20 years): 169 MV subjects versus 177 individuals with fluent verbal language. They plant no significant differences in the severity of self-injury, stereotyped behavior, and irritability (including aggression and anger) when data were controlled for age and nonverbal IQ. However, a trouble of sample choice bias can be hypothesized (of which the authors were also aware): all cases were "psychiatric inpatients," thus they were probable predisposed to behavioral problems.23
Concerning the prognosis of MV children with ASD, it is known that if a child manages to acquire verbal language, this usually occurs within five years of life.3 However, exceptions to this general dominion have been reported, considering that verbal linguistic communication tin can be acquired between 5 and vii years of historic period or (although more rarely) fifty-fifty afterwards, upwards to the historic period of 13 years.24 Regarding other aspects of the prognosis, the development of useful speech inside the age of 5 years seems to be a very important predictive factor of better outcomes in the following years, as it concerns adaptive and social functioning.3
How to define minimally verbal children?
The lack of a wide definition of MV children is somehow noteworthy. In the context of children with ASD, the proportion of those who are MV depends on the criteria used to identify them. For case, Kasari et al. defined MV children as those communicatively using "[…] a very small-scale repertoire of spoken words or stock-still phrases…"; the number of spoken words may greatly vary, ranging from 0 to 20–thirty, depending on several factors such as historic period and previous interventions.25 In gild to identify MV children, many researchers use clues deriving from the diagnostic tools for ASD. For instance, according to many authors, children are considered MV if they have been assessed through the Autism Diagnostic Observation Schedule (ADOS) — Module 1.26 The ADOS, currently available in its second edition, is present considered the gilt standard for the ASD diagnosis, and the Module ane of this calibration is focused on children aged over 30 months who speak few or no words.27 This method may exist preferable in some respects, considering that ADOS also allows the straight assessment of the individual, but it is not a foolproof method. In fact, Module 1 of the current version of ADOS consists of two submodules, devoted to children with greater or bottom language harm, respectively; consequently, the language of children who undergo this module can widely vary from the complete absence of speech to the regular use of expressions composed of 2 or more words (see particular A1 of ADOS Module 1).27 Therefore, including all these ASD children nether one definition of MV could be misleading; and it is a fact that, within the definition of MV, there are very dissimilar situations.26
Another method is based on the use of words according to parents' reports: it identifies children as MV when their linguistic communication skills are not exceeding those of a baby aged 18 months, who mainly uses single words or gestures for communicating; this is perhaps a less objective method than the previous one, but it gives information on the real everyday life of the child. Co-ordinate to the results obtained in a study on a big sample including 1478 ASD individuals aged 5-18 years, through the method of ADOS Module 1, 28% of ASD children should be MV; instead, according to the method of language skills not exceeding those of a xviii-month infant, only 13% should be MV.28
Therefore, it is evident that issues related to an exact definition of MV are paramount. For example, in a review addressing a certain ASD intervention, grouping, inside the MV phenotype, the data on the development of children who, at the commencement of the intervention, speak only one or two words with those of children who speak a few dozen words may atomic number 82 to significant misinterpretations of the obtained results.21
Koegel et al. carried out a systematic review of the definitions of nonverbal or MV individuals and the advice assessment measures in intervention studies aimed at improving expressive exact communication in ASD children. They institute relatively few studies focusing on verbal expressive communication in nonverbal or MV children with ASD. The authors verified keen inconsistencies in the adopted measures, in the definitions of "nonverbal" and "MV" children, and in the studied ages, which can cause confusion in the interpretation of the results of the diverse studies. They suggested guidelines for creating a more homogeneous evaluation protocol with systematic descriptions of the samples, in gild to understand the heterogeneity in these ASD individuals and to replicate the results of the enquiry that concerns them. The recommendations included in these guidelines refer, among other things, to the importance of: identifying the participants as nonverbal or MV; evaluating the language through standardized and observational measures, also considering a natural sample of interactive advice, if possible with a communication partner who is familiar to the child; and also examining the intellectual operation of the child.21
Neurobiology of minimally verbal individuals
Neurophysiological techniques, every bit well equally structural and functional neuroimaging ones, accept been applied to await for possible abnormalities in children with ASD, in guild to explain the evolution of language.20 Next, only some of the most relevant obtained results are demonstrated.
Ortiz-Mantilla et al. performed an electroencephalogram-based study to investigate neural mechanisms that underlie the visual processing of mutual objects in MV children with ASD. A paradigm consisting of a moving picture, followed by a word that could be correct or wrong, was presented to ten MV children of 4–7 years old with ASD and to 15 sex- and age-matched controls. Event-related cortical responses during visual stimulus processing were studied. When compared with controls, responses of lower amplitude and longer latency were recorded in MV children with ASD as well every bit other bioelectric alterations in the occipital and frontal regions. The authors ended that visual processing, both in the early and belatedly stages, is impaired in MV children with ASD, and at to the lowest degree some of their linguistic alterations could derive from an harm of cortical representations of the object and its exact label and also from a reduced allocation of attention to visual stimuli, which would have a negative touch on on dictionary acquisition.29
Concerning neuroimaging techniques, Knaus et al. studied possible anatomical differences between ASD individuals with more or less severely impaired expressive language and ASD individuals without such deficits using volumetric encephalon magnetic resonance imaging (MRI). They included 34 ASD boys aged 7–11 years divided into ii groups: individuals with impaired expressive linguistic communication (17 cases) and those with average or high language (17 cases) respectively. The first group was further subdivided into a depression (9 cases) and an extremely low (8 cases) language subgroup (this latter basically respective to MV children). The volume of the planum temporale (PT) was smaller in individuals with expressive language damage than in those without information technology. The right PT volume was positively correlated with expressive, receptive, and total linguistic communication abilities. The volume of the left PT was smaller in the individuals with extremely low linguistic communication than in those with average or moderately low language. The authors ended that, in ASD individuals, smaller PT volumes are associated with severe language impairments.xxx Moreover, cortical structural abnormalities in the junior frontal gyrus accept been reported for these children.31
On the other hand, information technology has been suggested that microstructural alterations of white thing tracts, such equally the arcuate fasciculus (connecting Broca's and Wernicke's areas) and the frontal aslant tract (connecting the posterior inferior frontal gyrus and the brain frontomesial region), showed by magnetic resonance with improvidence tensor imaging (DTI), may be involved in the impairment of speech communication of MV subjects with ASD.32
While ASD individuals ofttimes present a more or less severe impairment of language, music skills are usually preserved, although brain regions involved in these functions commonly overlap. Based on this observation, Lai et al. institute a college activation in the left inferior frontal gyrus in response to song stimulation through functional MRI in 36 ASD low-performance children, who were mostly MV, but a lower activation in response to speech communication stimulation. These results support the hypothesis of an atypical attention to auditory stimuli in ASD individuals: reduced for speech, just increased for songs.33
Yet, despite the described findings, it is still unknown how the reported brain functional and structural alterations might explicate the language problems in ASD children.xx To engagement, to the best of the authors' knowledge, in that location are no biological markers that identify MV individuals with ASD.
Cerebral mechanisms and linguistic communication in autism spectrum disorder
Several studies have addressed the topic of cerebral mechanisms likely involved in the altered or even absent development of exact language in ASD children. Although these studies have not achieved unequivocal and conclusive results, they suggested the presence of data supporting the interest of some variables related to social advice in expressive linguistic communication evolution, such equally joint attention, spontaneous play, gestures (including pointing), and imitation (both vocal and motor) abilities; moreover, the early nonverbal intellectual ability has been related to the development of expressive linguistic communication.34 – 37 In particular, articulation attention is the skill (commonly adult in the first year of life) of responding to others' social initiatives and spontaneously engaging in social interactions with other people, in addition to integrating these 2 abilities.38 Joint attention has been plant to predict the development of language skills in both typically-developing children and those with ASD34 , 38, and this is evidently a very important finding as well regarding interventions aimed at the development of long-term spoken language.39
Thus, an harm of joint attention, pointing, spontaneous play, imitation skills, together with a more or less astringent delay in verbal language development, are probable to be among the early symptoms of autism most often reported by parents when the kid ages upward to 18 months onetime.40
Treatment for minimally verbal children with autism spectrum disorder
Considering that most studies investigated communication-focused interventions in verbal children with ASD, while their efficacy in MV children with ASD is unknown, Brignell et al. performed a systematic review on this last issue.20 They considered randomized controlled trials (RCTs) related to communication-focused interventions for children with ASD who were MV, that is, according to their definition, children who spoke less than 30 functional words and/or were unable to use verbal language alone to communicate. The authors plant only two RCTs that compared MV children undergoing communication-focused interventions with MV controls undergoing their usual treatment. One RCT41 used a verbally-based intervention performed by parents at home (focused playtime intervention — FPI), while the other one42 used an alternative and augmentative communication (AAC) intervention carried out by teachers at schoolhouse through the Motion-picture show Commutation Communication System (PECS), which allows individuals to quickly communicate to others, for example, their needs using picture cards. The FPI written report considered seventy MV children with ASD and focused on promoting coordinated toy play between the parent (who had received a specific training) and the child. The AAC study considered 84 MV children with ASD who were not using the PECS method nevertheless. Brignell et al. found a very low overall quality of evidence due to the adventure of bias (including the lack of blinding for participants and personnel), imprecision (small size of the samples), and besides because only 1 trial was identified for each intervention type (verbally-based and AAC, respectively). Both trials mainly focused on verbal and nonverbal advice outcomes, and the study apropos AAC intervention also focused on social communication skills. The FPI trial showed no significant results in verbal communication. Nevertheless, cases with poorer expressive language before treatment improved more than those with better expressive language, and FPI promoted expressive linguistic communication improvements in some cases.41 The AAC study found that cases enrolled immediately postintervention used significantly more verbal initiations and PECS, only unfortunately these gains were not confirmed ten months later. In immediately postintervention, no significant improvements were plant with AAC on oral communication frequency, verbal expressive vocabulary, or social advice skills or pragmatic language.42 Overall, in most cases, both FPI and AAC trials showed no sustained gains in exact or nonverbal advice skills.20
Assuming that the role of parent education is essential for the treatment of ASD subjects and in item of MV ones, Koegel et al. performed a systematic review on the procedures of parent educational activity in intervention studies aimed at improving verbal communication of MV children. Unfortunately, they institute that merely 36 studies accept considered a parent educational activity component; in most manufactures, parent teaching programs were not clearly described, and only in few studies the implementation of parents' intervention was scored.43
All the same, although the literature on the thing has provided very few evidence-based results, several findings suggest that an intervention, such as the AAC, considering a communication aqueduct for the individual, may exist constructive in stopping the sequence of events that, in MV children with ASD, tin can cause frustration to build up and trigger challenging behaviors and, finally, accentuate social isolation (Figure two). In particular, PECS represents an effective means of enabling functional communication for individuals who have little or no oral communication, even though it showed a relative lack of relevant gains concerning speech.44 – 47 It is worth noting that AAC includes, in addition to PECS, other types of interventions, including the utilise of spoken language-generating devices (SGDs) that, upon command of the user, are able to produce previously recorded or computer-generated speech.48 SGDs seem to be most constructive for ASD individuals without intellectual/developmental disorders (IDD), especially in preschool age, whereas PECS seems to be about effective for ASD individuals with IDD.48
Augmentative and alternative advice in minimally verbal children with autism spectrum disorder. Each white arrow indicates a predisposing effect; the blackness arrow indicates an inhibiting effect. See text for details.
Discussion
Commencement, the limitations of this narrative review should exist mentioned, which are basically related to a possible selection bias due to the subjective evaluation of the studies on the part of the authors. Yet, it is worth highlighting that the study methodology of a narrative review is more indicated than a systematic review in cases when the aim is to provide a broad perspective on a subject.49
Although to engagement there are many notions about the clinical aspects of ASD, including diagnostic criteria, associated disorders, prognosis, and effective treatments, there is no agreement yet on the exact and detailed definition of MV children with ASD or on how to precisely identify them. Hence, the verbal number of MV children with ASD is unknown, but information technology is surely loftier, particularly based on the well-nigh recent epidemiological data nearly the full general prevalence of ASD.6 From the authors' perspective, in order to better understand the clinical features and the neurobiological correlates of this subgroup of individuals with ASD, it would be advisable to ascertain them with very rigorous diagnostic criteria, because individuals equally MV only when their language level corresponds, at virtually, to the level of single words, and their chronological age is at least 5–7 years, considering that a meaning recovery of language skills is much more unlikely later on in life.24 It is evident, for instance, that the situation of a 3-twelvemonth-old child who does non speak, nevertheless theoretically being susceptible to great improvements, could be very different in prognostic terms from that of a 10-year-old kid who does not speak and who probably never will in his/her life. Perhaps also due to these uncertainties regarding a correct definition, the reasons why MV children with ASD do not speak are unknown, although some hypotheses emerged from the results of studies based on neurophysiological and structural/functional neuroimaging data. At a clinical level, in the context of children with ASD, the authors believe that the effort to notice whatever correlate in terms of neuroimaging should be primarily made precisely in those who are MV, seeking — for example — any alterations of the encephalon connectivity through DTI techniques. Furthermore, behavioral issues are more than frequent and complex in MV children than in those who are able to develop linguistic communication, often involving significant management difficulties, just there is lack of evidence-based sit-in of the effectiveness of ASD interventions focused on communication in MV children. Therefore, further studies must be conducted on these individuals who, non surprisingly, take been called some years ago by some authors as "the neglected stop of the spectrum."3
Although prove-based data are lacking, several findings suggest that interventions, such as the AAC, and in particular PECS, may be constructive in enabling functional advice in MV children with ASD.44 – 47 This blazon of intervention is very important because, by bypassing the lack of exact language, it can requite a means of communication to these individuals who, among people with ASD, are certainly those who crave more care and attention and whose management involves high social and welfare costs, regardless of the emotional suffering produced in their caregivers.
In improver, more research is needed to understand the natural history of MV individuals with ASD from the beginning. For example, is information technology possible that subjects who brandish developmental regression equally their onset way (the so-called regressive autism) are, therefore, (at least for the most part) the same who remain MV during their life? Still present, information technology is very difficult to find a clear and conclusive answer to a relatively simple question such as this in the literature.4
In determination, the authors believe that the event of MV individuals with ASD should be addressed by finding a shared definition of this condition characterized past very rigorous clinical criteria and by systematically studying these patients at a genetic, neurophysiological, and neuroimaging levels, too aiming at finding whatsoever distinctive neurobiological correlates that may possibly represent the starting betoken for more targeted and specific enabling interventions.
Acknowledgment
The authors would like to thank Cecilia Baroncini for linguistic support.
Footnotes
Funding
This study did not receive whatever funding.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432069/
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