HOW TO ADVANCE COGNITIVE AND

LINGUISTIC DEVELOPMENT OF PERSONS

WITH COGNITIVE DEVELOPMENTAL

DISORDERS?

Dr. Krisztina Bohács PhD

GEM Cognitive Clinic

ELTE

INTRODUCTION

Intellectual disability (ID) -- still a major health, educational

and social problem in the 21st century

Individuals with ID need special ways of instruction and

contents structured and layered according to their thinking

patterns

Passive acceptant approach (adapting the environment to the

present level of functioning of the individual) ↔ Active

modifying approach (enriching the individual’s copying

behaviour for a better quality of life)

INTRODUCTION (RESEARCH)

A large number of research studies have been carried out in order to determine best ways of teaching academic subjects, reading and mathematics to children with cognitive impairments (Buckley & Bird, 2001; Buckley, 2002; Ghesquiére & Ruijssenaars, 2005; Browder & Spooner, 2011).

However, relatively little attention has been paid to the cognitive development of children with developmental disabilities /Down syndrome, other genetic syndromes, pervasive developmental disorder (PDD) or cerebral paresis (CP)/.

Even less research on the impact of cognitive acceleration programs on children with serious cognitive and learning problems is rather limited (esp on programs that target fluid intelligence) (Kozulin et al., 2010).

THEORETICAL BACKGROUND I

DESCRIPTION OF ID;

DEFINITIONS AND CLASSIFICATION OF IDS

Based on IQ Scores Diagnostic and Statistical Manual of Mental Disorders, DSM – 4 in

Hu:

Borderline Intellectual Functioning: IQ 71-84;

Mild Intellectual Disability IQ 50-55 to appr. 70;

Moderate Intellectual Disability: IQ 35-40 to 50-55;

Severe Intellectual Disability IQ 20-25 to 35-40;

Profound Intellectual Disability: IQ below 20 or 25

Older approach – still permeates decisions of placement in

the segregative special school approach

THEORETICAL BACKGROUND I

DESCRIPTION OF ID;

DEFINITIONS AND CLASSIFICATION OF IDS

New DSM – 5: American Psychological Association’s annual meeting, San Francisco, May 2013

Emphasizes the change for a more comprehensive assessment – consideration of adaptive functioning rather than IQ test scores alone.

„By removing IQ test scores from the diagnostic criteria, but still including them in the text description of intellectual disability, DSM-5 ensures that they are not overemphasized as the defining factor of a person’s overall ability, without adequately considering functioning levels.”

THEORETICAL BACKGROUND I

THEORETICAL GROUNDS AND GENERAL PROBLEMS IN

COGNITIVE ACCELERATION

Main approach to ID: sensorial/motoric programs: into the motoric modality they infuse the simple mental operations of pairing, matching, sorting and sequencing’ (sometimes claimed to be „thinking” programs) -- „functional learning”, „meaning derives from effortful movement”, „purposeful doing approach”.

Metacognitive, thinking skills programs: refined abstract labels, operations are completed not (only) by ‘doing’, but in an internalized way on the level of mental representations. Emphasize decontextualisation of abstract principles from the concrete experience and explicitely mediate transfer: the recontextualisation of the generalized strategies into new contexts. Higher self-regulation in terms of behaviour in general and while learning.

THINKING SKILLS PROGRAMS

THEORETICAL BACKGROUND I

OVERVIEW, COMPARISION AND CLASSIFICATION OF AVAILABLE

COGNITIVE ACCELERATION PROGRAMS

FIE-Basic: The reason for our choice:

In Hungary we did not find any structured cognitive program that would systematically target fluid intelligence of children with ID.

This strong and high level of abstraction usually does not characterise other interventional approaches to intellectual developmental disabilities. Develops representational thought.

Represents metacognitive approach to early education (self-regulation).

THEORETICAL BACKGROUND II

LEARNING EXPERIENCE&BRAIN PLASTICITY (DEFINITIONS,

OVERVIEW OF HISTORY) AIM: TO CONVERGE NEUROSCIENCES AND COGNITIVE EDUCATION; CRITICAL ELEMENTS

IN COGNITIVE EDUCATION TO PROMOTE NEURAL PLASTICITY

The concept is a very important fundament of any

therapeutic intervention and on the level of psychological functions it may be called ’Structural Cognitive Modifiability’ or SCM.

The terms brain plasticity, neuroplasticity or neural-re-mapping : the brain’s ability to re-organize itself in micro- and macro-levels, according to new experiences, learning or injury (LeDoux, 2003; Kleim & Jones, 2008; Doidge, 2007; Joja, 2013).).

Conclusions of brain science on therapy/cognitive acceleration (Intensity effect; novelty effect; spread effect; persistence effect etc.) --- similar to the criteria of MLE

THEORETICAL BACKGROUND III

STRUCTURAL COGNITIVE MODIFIABILITY (SCM)

In line with modern brain placticity research in the 21th century, the SCM model has viewed the human organism as open, adaptive and amenable for change since already the 1950’s (Feuerstein, 1979).

It involves the capacity of the individual to be modified by learning and the ability to use whatever modification has occurred for future adjustments -- due to environmental demands (Feuerstein, Feuerstein & Falik, 2010).

In SCM model intelligence is defined as a changeable state rather than an immutable trait. Following Piaget, in this model cognition plays a central role in human modifiability.

THEORETICAL BACKGROUND IV

SHORT OVERVIEW OF FEUERSTEIN’S THEORY AND

APPLIED SYSTEMS

Piaget, Vygotsky and Feuerstein – Views about the

modifiability of intelligence Piaget: construction driven by biological maturation; Vygotsky: material tools

and psychological tools; Feuerstein: humans – intentionaliy/reciprocity;

meaning and transfer

Criteria of Mediated Learning Experience

The Deficient or Emerging Cognitive Functions

The Cognitive Map – Dimensions of the Task

FEUERSTEIN’S MLE

The therapist/caregiver interposes himself between a set of stimuli and the learner and modify the stimuli for the developing child (Feuerstein, 1979; Tzuriel, 2011). Focusing the child on selected aspects of stimuli by

changing the intensity, frequency and order of the stimuli; by arousing the child’s vigilance and perceptual acuity; and by trying to develop in the child the cognitive functions required for temporal, spatial and cause-and-effect relationships.

MLE processes are gradually internalized by the child so as to become an integrated mechanism of change within the child.

Provision of adequate MLE facilitates the development of various cognitive functions, learning sets, mental operations, strategies and need systems.

THEORETICAL BACKGROUND V

PROBLEMS WITH ASSESSMENT OF CHILDREN WITH ID

Need of assessment systems -- penetrate deeper, much more into the ’latent intelligence’ of the low-performing individual which may be hindered by physiological and affective-emotive factors.

Physiological, social, emotional, cognitive aspects are all closely interwoven in the low-performing child, that under standardized circumstances (when interferences are avoided, different types of questioning or feedback are not allowed for the sake of reliability, when greater intentionality in the interaction is forbidden), objective „measurement” of cognitive

abilities is not possible (Resing, 2000; Haywood & Lids, 2007).

For a molar intervention plan we need to make explicit the child’s learning strategies.

THEORETICAL BACKGROUND V

DYNAMIC ASSESSMENT

A new testing paradigm has evolved since the 1970’s (DA). Its philosophy originates from the social constructivist theories of Vygotsky (ZPD).

Dynamic Assessment (DA) should make it possible to evaluate the person’s learning potential/propensity, not just his or her actual knowledge and skills.

An active teaching process of a child’s perception, learning, thinking

and problem solving takes place. The process is aimed at modifying an individual’s cognitive functioning and observing subsequent changes in learning and problem solving patterns within the testing situation (Tzuriel, 2001, Lifshitz et al., 2011).

Unlike other assessments, where examiners seek to document an individual’s existing repertoire of cognitive abilities and make no attempt to change, guide, or improve the individual’s performance, the main goal of DA is to assess changes in performance. The changes are taken as indications of learning potential, that is, future development that will be realised provided that a cognitive intervention is applied (Tzuriel, 2011).

Dynamic

Assessment

Curriculum-based DA Content-free DA, Evaluating

pure cognitive structures

Standardized,

quantitative

Non- standardized,

qualitative

W. Resing (2000),

C. Lidz (2007), V. Aalsvoort

(2002)

R. Feuerstein, LPAD (1963)

D. Tzuriel (2001)

R. Deutsch&Mohammed

(2010)

Computerised DA

J. Guthke &J. Beckman

H. Swanson, C. Wiedl,

D. Tzuriel (2001)

M. Jensen, Guthke,

Raider& Caruso (1991);

Fiszdon& J. Johannesen

(2010); Jensen (2007)

DA in Second

Language Acquisition

Poehner (2008)

Figure 4.2 Classification of Dynamic Assessment Systems (Resource: Bohács, 2010 p. 314).

THE EMPIRICAL RESEARCH

The cognitive-affective rehabilitation of 15 children born with ID and other comorbid phenomena (autistic behaviors, obsessive-compulsive disorder /OCD/, ADHD and pervasive developmental disorder /PDD/) with a socioconstructivist cognitive intervention program (Feuerstein’s MLE, Mediated-Self Talk and FIE-Basic). A thorough intervention in a clinical laboratory for 24 months.

THE APPLIED INTERVENTION PROGRAM

FIE-Basic

Mediated Self-Talk

within the framework of Mediated Learning Experience as

for way of interaction

The time of acceleration: 24 months in each cases

Type of intervention sessions: one-to-one, this way deficient cognitive functions of the individuals could be targeted with greater precision than in group settings

Intensity: large (7-15 sessions per week) (about 1400 hours per child)

INTERVENTION PROGRAM, THE INSTRUMENTS

1. Organisation of Dots – Basic

2. Orientation in Space – Basic

3. From Unit to Group

4. Identifying Emotions

5. From Empathy to Action

6. Compare and Discover the Absurd

7.Tri-Channel Attentional Learning

8. Know and Identify

9. Think and Learn to Prevent Violance

10. Learning to Ask Questions for Reading Comprehension

11. Compare and Discover the Absurd – Basic Level 2

PARTICIPANTS, AIMS AND RESEARCH

QUESTIONS

Participants of our qualitative study (N=15) are randomly chosen individuals from all parts of the country and from all socio-economic backgrounds.

They have mild (n=5) to moderate intellectual developmental disorder (n=10) with very different etiology (genetic syndromes, cerebral paresis, perinatal brain injury and/or metabolic diseases) +

severe comorbid atypical behavioural and motoric phenomena atypical cognitive-emotive behaviours (autistic behaviour /auditory or

tactile sensitivity/, obsessive-compulsive behaviours, severe ADHD and/or motoric dysfunctioning (dyspraxia, ataxia and hemiphlegia).

Language: 4 children (Cases 3, 9, 11 and 13) non-verbal; 4 arrived for intervention with very restricted language abilities – holographic one-word or two-word sentences or fragmented speech.

METHODS OF THE EMPIRICAL RESEARCH

I. Multiple embedded case studies „In the field of cognitive psychology when complex markings of

impaired and unimpaired cognitive functions are examined, case studies are the most tangible ways of hypothesis testing.” (Szokolszky, 2004, p. 498).

Our research is viewed as a series of experiment where the cases can be interpreted as the repetition of the same intervention program and this “replication logic” is supposed to reveal support for theoretically similar results; or contrasting results for predictable reasons (Yin, 2003).

However, two of the main drawbacks of case studies are their vast demand of time and resources” (Szokolszky, 2004, p 499).

II. Descriptive Statistics and Test Statistics ‘Flexibility of the qualitative studies is not a reason to avoid

systematic and consequent handling of data. Summarizing all the data in tables and the endeavour to quanitfy the results helps to maintain the validity of the research (Szokolszky, 2004, p 411)’.

AIMS AND RESEARCH QUESTIONS

Not to test the effectiveness of FIE-Basic per se BUT what kind of changes we can elicite in the cognitive-behavioural condition of our participants; how far we can take them with our intervention.

The main hypothetical questions:

Hypothetical Question 1

We have evidence from international research studies that MLE and FIE-Basic have a positive effect on children with regular intelligence or children in the socially disadvantaged population (Ben-Hur &

Feuerstein, 2011; Salas et al., 2010). Is this possible to elicit changes in the development of fluid intelligence of children with moderate and mild intellectual disability as well?

AIMS AND RESEARCH QUESTIONS

Hypothetical Question 2

Is it possible to elicite changes in the participants’ conceptual development, receptive/expressive language and communication? Based on Ben-Hur’s and Feuerstein’s study (Ben-Hur & Feuerstein, 2011, see Chapter 3.6) we expect that the program will positively influence not only regular children’s conceptual development but also those who have intellectual disability.

Hypothetical Question 3

Is this possible to enhance the logic, reasoning abilities of children having moderate and mild intellectual disability? Based on Beasley we hypothized that our intervention will bring about changes in reasoning abilities of children in our atypical group as well (Beasley, 1984).

AIMS AND RESEARCH QUESTIONS

Hypothetical Question 4 Is this possible to develop these children to

metacognitive awareness, self-regulation and internalized psychological control while learning? The study of Alas et al. note that one of the effects of FIE-Basic on socially disadvantaged children was that their self-regulation have improved and the experimental group became less distracted (Alas et al, 2010). Based on Alas and the several criteria of MLE we expect that there will be growth in children’s self-regulation while treating stimuli.

Hypothetical Question 5 Will the elicited changes generalize to other areas

that we cannot prognose? Based on one of Feuerstein’s criterion about SCM (the generalizability of a change) we prognose that the induced changes will affect other areas of the individual’s functioning (Feuerstein, Rand & Feuerstein, 2006).

BLENDED ASSESSMENT – STATIC

TESTS+DYNAMIC ASSESSMENT SYSTEMS

Static tests:

Raven Coloured Matrices (Raven, 1938)

Peabody Passive Vocabulary Test (Dunn & Dunn, 1997)

Gardner Active Vocabulary Test (Gardner, 1990)

TROG Test (test for the Reception of Grammar) (Bishop, 1983)

DIFER (Nagy, Józsa, Vidákovich & Fazekasné, 2004)

Goodenough-Harris Drawing Test (Goodenough, 1926)

DYNAMIC ASSESSMENT SYSTEMS

Cognitive Abilities Profile (CAP) (Deutsch&Mohammed,

2009)

(attention, memory, receptive/expressive language, cognitive

operations, metacognition and behaviours while learning.

Learning Propensity Assessment Device Basic

(LPAD-Basic) (Feuerstein et al., 1999)

RESULTS

Some Cases

Summative Results

CASE 1 PRE-TEST HUMAN FIGURE DRAWING, APRIL

2007. RAW SCORE: 1. DQ: CATEGORY A.

CASE 1 SPONTANEOUS HUMAN FIGURE DRAWING, AFTER A

SESSION IN THE PRESENCE OF HIS FATHER. SEPTEMBER

2007. DQ: 47.

The child has started to

make relationships between

episodic data and integrate

visual and visuo-motor

skills. The effects of the

’Organisation of Dots’ tool

are obvious in the drawing:

one square form and dots

everywhere, vertical and

horizontal lines comprise

the visual organisation of

the child.

CASE 1 POST-TEST: „MY FATHER AND HIS CASTLE AND HIS HORSE,

JUST PULLING A CART. MY FATHER IS A KING AND I TRY TO DEPICT HIS ROBE

ON HIS ARMS”. APRIL 2009. DQ: 84.

CASE 3 PRE-TEST HUMAN FIGURE DRAWING, NOVEMBER 2007.

CRONOLOGICAL AGE: 5;7 YEARS. RAW SCORE: 1.DQ: CATEGORY A.

CASE 3 SPONTANEOUS HUMAN FIGURE DRAWING. TITLE

GIVEN BY THE CHILD: „A PASTRY-COOK HOLDING A SUNSHINE

COOKIE”. FEBRUARY 2009. DQ 90.

CASE 4 PRE-TEST HUMAN FIGURE DRAWING, JUNE

2008. CRONOLOGICAL AGE: 12;7 YEARS DQ: 38.

CASE 4 POST-TEST HUMAN FIGURE DRAWING. THE TITLE

GIVEN BY THE CHILD: „ME IN A SQUARED SHIRT.” JUNE 2010.

DQ: 60.

CASE 14 PRE-TEST HUMAN FIGURE DRAWING, DECEMBER

2010. CRONOLOGICAL AGE: 4;8 YEARS. DQ: CATEGORY „A”.

CASE 14 SPONTANEOUS HUMAN FIGURE DRAWING, NOVEMBER 2011. THE TITLE

GIVEN BY THE CHILD ‘MOTHER’. CRONOLOGICAL AGE:5;7 YEARS. DQ 95

CASE 14 SPONTANEOUS HUMAN FIGURE DRAWING. THE TITLE GIVEN BY

THE CHILD:„MUM”. APRIL 2011. CRONOLOGICAL AGE: 5;0 YEARS. DQ 80

CASE 14 SPONTANEOUS HUMAN FIGURE DRAWING. THE TITLE

GIVEN BY THE CHILD: „MY FAMILY HOLDING EACH OTHER’S

HAND”. DECEMBER 2012. CRONOLOGICAL AGE: 6;1 YEARS.

DQ 98

The child has

started to depict

human relations –

which is a virtual,

abstract concept.

This indicates

serious cognitive-

emotive

development in

Pervasive

Developmental

Disorder.

TABLE 15. AVERAGE IMPROVEMENT IN RAVEN’S COLORED MATRICES, PPVT AND

GARDNER’S EXPRESSIVE VOCABULARY TEST IN 2 YS

Mean of

improvement

Standard

deviation

Min.

Max.

Theoretical

maximum

Average

percentage

points of

improvement

Raven 10,57 5,90 0 24 36 29,37%

PPVT 43,71 23,76 11 101 150 29,14%

PPVT

(mental age in

months)

46,43 =

3 years, 10 months 20,06 12 90 - -

Gardner T 32,29 15,55 5 69 79 40,87%

TABLE 16. RESULTS OF PAIRED-SAMPLES T-TEST AND WILCOXON SIGNED-

RANK TEST (N=14)

Table 16. Results of Paired-samples T-test and Wilcoxon signed-rank test (n=14)

95%

confidence

interval of the

difference

Nonparametric

test for two

related sample

Mean

Standard

deviation

Standard

error of

mean Lower Upper t df Wilcoxon’s Z

Raven 10,57 6,12 1,64 7,04 14,18 6,460*** 13 -3,185**

Peabody 43,71 24,66 6,59 29,48 57,95 6,634*** 13 -3,296***

Gardner 32,29 16,14 4,31 22,97 41,61 7,484*** 13 -3,297***

Differences in cases with moderate ID

Raven 9,22 7,31 2,44 3,60 14,84 3,784** 8 -2,533*

Peabody 49,22 27,72 9,24 27,91 70,53 5,327*** 8 -2,666**

Gardner 35,11 19,40 6,47 20,20 50,02 5,430*** 8 -2,666**

Differences in cases with mild ID

Raven 13,00 1,87 0,84 10,68 15,32 15,538*** 4 -2,032*

Peabody 33,80 15,74 7,04 14,26 53,34 4,802** 4 -2,023*

Gardner 27,20 6,61 2,96 18,99 35,41 9,201*** 4 -2,032*

*** - p<0,001; ** - p<0,01; * - p<0,05

Notes: SD: This is the corrected standard deviation (the sum of squares divided by n-1

instead of n).

SUM OF RESULTS ON COGNITIVE ABILITIES

PROFILE (REASONING/LOGIC; LANGUAGE/COMMUNICATION; BEHAVIOURS)

RESULTS

Q1 (fluid intelligence)

Raven Colored Matrices showed an increase in general

intelligence by 29,37%p within the two year long intervention

period. PPVT has indicated a 3 year 10 month growth in

mental years within the two year long intervention time.

Analysis by test-statistics has indicated that there were

significant changes in the cognitive development of the

participants between pre-test and post-test measures on

Raven’s Colored Matrices (mean 10,57, SD=6,12, t=6,460,

p<0,001;).

RESULTS

Q2 (language, communication)

Analysis by test-statistics has indicated that there were

significant changes in receptive language of the participants

between pre-test and post-test measures on Peabody Passive

Vocabulary Test (mean 43,71, SD=24,66, t=6,634, p<0,001)

and Gardner’s Expressive Vocabulary Test (t=7,484, p<0,001;

mean 32,29, SD=16,14).

Results of Cognitive Abilities Profile also indicated that the

participants development had been striking in the domain of

language and communication (improved by a mean of

55,36%p within the two years long intervention).

RESULTS

The titles of the individual human figure drawings of the

participants also indicate that their conceptual development

(presented in the titles of the drawings) have become very rich

verbally.

Individual TROG test results have strengthened that

understanding syntactic structures has also developed,

generally between 2;4 -- 5;2 years during the 24 months long

intervention phase.

Out of the 4 non-verbal children 3 became verbal

RESULTS

Q 3 (reasoning)

According to Cognitive Abilies Profile results the domain of reasoning improved by 57,40%p within the 2 years. This proved to be the highest difference between pre- and post test measures by CAP.

70% of them has presented a constant comparative behaviour, a need to

compare everything they experienced and figure out a criteria for commonalities.

The appearance of ’Why’ and ’What for’ questions also suggest that their episodic world-view has started to decrease and they started to find relationship between objects, events or situations. All the individual drawings show as well that children started to sythetise their experience.

RESULTS

Q4 (self-regulation, metacognitive awareness)

According to CAP, strategic thinking and metacognition have grown by 53,75%p in two years. We may interpret children’s advancement on Raven test

also that they have a better regulation of their learning processes. CAP: a 56,1%p growth in the domain of ’Behaviours while learning’.

We mention from individual cases we could lead 74% of children with

intellectual disability to cognitive and metacognitive awareness – they could clearly recognise and name the operations they have been doing with concrete or abstract data (’I am comparing these three objects according to height’; ’I am creating a sequence where the number of the objects are growing by two’) and they could recognise simple operations in other context.

RESULTS

Q5 (generalisation)

Our participants have started to draw human

figures, family members or objects in a

spontaneous way parallel the cognitive intervention.

The rhythm, the growing quality and ease with

which these drawings have been created imply that

this process can be interpreted as a sign of

modifiability. No other studies have noted this

generalized change.

Development of human figure drawings means a

sythetized cognitive, motor and verbal

development.

FIGURE 104. DIAGRAMS OF HUMAN FIGURE DRAWING DEVELOPMENT --

AVERAGE PROGRESS OF CHILDREN WITH MODERATE ID IN TWO YEARS (SUM)

0

20

40

60

80

100

120

Pre 1st year 2nd year

Average progress in two years - cases with moderate ID

Case 1

Case 2

Case 3

Case 4

Case 5

Case 8

Case 9

Case 12

Case 13

FIGURE 105. DIAGRAMS OF HUMAN FIGURE DRAWING DEVELOPMENT --

AVERAGE PROGRESS OF CHILDREN WITH MILD ID IN TWO YEARS (SUM)

0

20

40

60

80

100

120

140

Pre 1st year 2nd year

Average progress in two years - cases with mild ID

Case 6

Case 7

Case 10

Case 14

Case 15

CONCLUSIONS

Our research has strengthened that the „boundaries of human

intellect can be enlarged” (Csapó, 2013), even in case of the

clinical population where traditional approach views abilities

as constant and immutable or minimally plastic. The

enhancement of fluid intelligence of children with intellectual

disability is possible.

There is a much wider „hidden” or „latent” learning potential in

most children belonging to the clinical population than we

have had earlier hypothesized -- given a thorough, molar,

individually tailored and intensive program focusing on

precognitive, cognitive, and metacognitive elements of

learning.

NOVELTY

The novelty of our research is that in Hungary a metacognitive

thinking skills program has never been applied with students

with intellectual disabilities

A novel approach to monitoring the condition of our

participants with dynamic assessment besides normative tests

– which let us clearly see possible molar developments not

necessarily indicated by regular testing procedures

FURTHER RESEARCH

Further research is needed to clarify the effectiveness of the

program -- more participants and control group. These

directions, however require considerable amount of financial

investments and time.

Very expensive program and demanding in terms of human

resources

THANK YOU FOR YOUR ATTENTION!

kbohacs@medialttanulas.hu