high motivation which can be supported by reinforcements [27, 116]. Murray and colleagues [104] found that two treatment programmes using PML aimed for CAS had suggestive or preponderant evidence, Integral Simulation/Dynamic Temporal and Tactile Cueing (DTTC) and Rapid Syllable Transition Treatment (ReST), with 14 children in each study. In a later study by Murray et al. [117] on a larger population of children with CAS comparing two treatments, effects were shown using ReST and the Nuffield Dyspraxia Programme-Third Edition (NDP3). CAS is a rare diagnosis, and at the clinic, the children often have co-occurring symptoms with other motor-based diagnoses including dysarthria features [13, 103], and a few single case studies on CAS inform that the children also were diagnosed with dysarthria [118–120]. In these studies, they performed an intervention with DTTC which showed less progress in some cases with mixed diagnoses though the studies did not problematise if the neuromuscular dysfunctions of dysarthria made an impact on the outcome. All the PML studies presented above had positive outcome on treated sounds and words which seems to be the biggest achievement this treatment strategy gives to children with CAS [121]. Less effect is noted on non-treated words, intelligibility and speech fluency though most studies did last for a fairly short period of time and acquisition of the new skills can prolong [105]. Pennington et al. [106] made a review on speech treatment for children with developmental dysarthria including the use of PML strategies. Pennington found that a few small observational studies had positive results on intelligibility and clarity of voice which gave impact on the children's participation in social and educational activities and quality of life. Also, Lee Silverman Voice Treatment (LSVT LOUD) works in the context of motor learning and activity-dependent neuroplasticity. Part of the goal is to strengthen muscles orally and for breath support to facilitate speech output. Research has shown positive outcomes indicating development of vocal loud-

ness and intelligibility in children with dysarthria secondary to CP [122, 123].

Motor learning principles are also involved in methods which try to incorporate input from several sensorimotor processing areas. Some are used for many decades, and others are emerging.

The Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) approach indicated that the use of multisensory input through auditory, visual and tactile-kinaestheticproprioceptive cues triggering specific facial muscles for each phoneme leads to a greater impact on speech development compared with children lacking sensorimotor input. In recent studies with children that had motor control issues as part of their speech disorder such as jaw sliding, jaw over extension and inadequate lip rounding/retraction, the PROMPT treatment showed to have effect on treated and untreated words, development of speech sounds and speech motor control [124–128]. PROMPT also seems to support positive development of motor speech movement patterns and intelligibility for children with CP [129, 130]. Another fairly new treatment method using biofeedback has been investigated in children with CAS. In biofeedback there is visual feedback with real-time ultrasound images of the tongue. Development of their ability to produce some of the practised target sounds was found, and

**6.4. Treatment strategies based on multisensory input**

*6.4.1. Multisensory cues for muscles used in speech*

122 Advances in Speech-language Pathology

a transfer into word production was also seen [131].

One model by Ayres [132] using exercises for development of sensory integration is based on the notion that the ability to process sensory information affects behaviour and learning. A few studies exist where speech development is measured. Ayres conducted a study with children suffering from apraxia and SLI, using sensory integration intervention, and found that the four children in the study increased their expressive language abilities [89]. And, another study involving children with ASD showed an increased complexity of utterance after sensory-based interventions [133]. One neurophysiological study on 17 children with CP using brainstem auditory evoked potential (BAEP) examination with significant improvement of transmissions in the auditory pathway section of the brainstem was measured after rehabilitation with Masgutova Neurosensorimotor Reflex Integration (MNRI) [134], a new form of a manual neuromodulation technique [135]. Hypothetically this improvement could lead to increased function in auditory processing. Several intervention studies with MNRI have recently been published mainly on children with NDD [136] however nonfocusing on speech outcome.

### **7. Conclusion and implications for therapy models used in MSD**

There is still very little empirical evidence; however, a respectful volume of clinical experience for treatment addressed children with MSD. Recently, more studies have been published especially concerning treatments with motor learning strategies, and the future looks prosperous. As we have been discussing in this chapter, it is noted that children with MSD can suffer from comorbidity in several areas such as fine and gross motor including posture control dysfunctions and sensory processing disorders even when there is no NDD found. We have also presented neural correlates giving evidence for the co-occurrence and interaction of different motor skills in several brain regions which give strength to the hypothesis that motor, speech and language dysfunctions seldom come alone and can be symptoms of an underlying global deficit. This enhances the question if therapeutic models ought to work with a holistic perspective reinforcing sensorimotor processing functions (e.g. oral and manual proprioception, postural, visual, auditory and tactile) on several levels of the brain as part of a treatment approach premised on the notion that the functions of the extrapyramidal nervous system must be addressed in the case of abnormal sensorimotor integration [134]. Maybe if there is an underlying core deficit, it could be reached through corrections of the dysfunctional basic sensorimotor patterns enhancing development of adequate motor responses leading to functional behaviour [134] as also proposed by Kent [105] concerning oral-motor exercises as we earlier quoted under Section 5.2. Even though sensorimotor approaches like MNRI and others based on PML such as PROMPT, DTTC or ReST show some promising results in research and clinical experience, more studies are needed confirming evidence-based treatment models in MSD. Future case-control study designs and especially randomised-controlled trials would be very valuable. Our experience with MSD population is that it is a complex group with a variety type of subtle problems. Trying to achieve a study group as homogeneous as possible seems to be important for the statistical power of studies. However, such studies could affect the generalisation of the results. We suggest using clinical experience as an integral guide for inclusion criteria and the design of the studies. We welcome more research on existing as well as new treatment models increasing quality of life for children with MSD.

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### **Author details**

Helena Björelius1 \* and Şermin Tükel2

\*Address all correspondence to<EMAIL_ADDRESS>
1 Department of Speech and Language Pathology, Oral Motor Centre, Danderyds Hospital, Stockholm, Sweden

2 Faculty of Health Sciences Department of Physical Therapy and Rehabilitation İzmir University of Economics, İzmir, Turkey

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1 Department of Speech and Language Pathology, Oral Motor Centre, Danderyds Hospital,

2 Faculty of Health Sciences Department of Physical Therapy and Rehabilitation İzmir

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Helena Björelius1

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132 Advances in Speech-language Pathology

**Section 2**

**New Research Results About Speech and**

**Language**

**New Research Results About Speech and Language**

**Chapter 8**

**Provisional chapter**

**Information and Impression Regarding ASD**

**Information and Impression Regarding ASD**

Cibelle Albuquerque de la Higuera Amato,

Cibelle Albuquerque de la Higuera Amato, Daniela Regina Molini-Avejonas and Cristina

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Daniela Regina Molini-Avejonas and

http://dx.doi.org/10.5772/intechopen.70397

Cristina de Andrade Varanda

de Andrade Varanda

**Abstract**

**1. Introduction**

**Questionnaire Answered by Foreigners Living in Brazil**

Autism Spectrum Disorders (ASDs) constitute a group of disorders characterized by changes present at early ages and manifesting in the areas of development of communication, behavior, and interpersonal relationship. Because ASD significantly affects communication and the social skills, all multicultural context needs to be better investigated. There is an urgent need to understand the impact of migratory process, bilingual environment exposure on the language development of children with ASD. The present study aims to present the results of 657 foreign residents in Brazil that answered an online questionnaire to know the consolidated information about ASD. Participants from 23 countries responded to the survey. Bolivia and Argentina were the countries with the highest number of participants. The present study found that 100% of the participants have heard of autism. About 80.6% of the sample had a family member with autism. The sociodemographic diversity identified in this study reflects the sociocultural diversity present in Brazil, besides reinforcing the importance of considering this population when

thinking about strategies and behaviors directed at individuals with ASD.

**Keywords:** Autism Spectrum Disorder, knowledge, lay beliefs, survey

**Questionnaire Answered by Foreigners Living in Brazil**

DOI: 10.5772/intechopen.70397

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Autism Spectrum Disorders (ASDs) constitute a group of disorders characterized by changes present at early ages and manifesting in the areas of development of communication, behavior, and interpersonal relationship. Early diagnosis and intervention are essential for the prognosis [1]. The Centers for Disease Control and Prevention (CDC) estimate the prevalence

**Provisional chapter**

### **Information and Impression Regarding ASD Questionnaire Answered by Foreigners Living in Brazil Questionnaire Answered by Foreigners Living in Brazil**

**Information and Impression Regarding ASD**

DOI: 10.5772/intechopen.70397

Cibelle Albuquerque de la Higuera Amato, Daniela Regina Molini-Avejonas and Cristina de Andrade Varanda Daniela Regina Molini-Avejonas and Cristina de Andrade Varanda Additional information is available at the end of the chapter

Cibelle Albuquerque de la Higuera Amato,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70397

### **Abstract**

Autism Spectrum Disorders (ASDs) constitute a group of disorders characterized by changes present at early ages and manifesting in the areas of development of communication, behavior, and interpersonal relationship. Because ASD significantly affects communication and the social skills, all multicultural context needs to be better investigated. There is an urgent need to understand the impact of migratory process, bilingual environment exposure on the language development of children with ASD. The present study aims to present the results of 657 foreign residents in Brazil that answered an online questionnaire to know the consolidated information about ASD. Participants from 23 countries responded to the survey. Bolivia and Argentina were the countries with the highest number of participants. The present study found that 100% of the participants have heard of autism. About 80.6% of the sample had a family member with autism. The sociodemographic diversity identified in this study reflects the sociocultural diversity present in Brazil, besides reinforcing the importance of considering this population when thinking about strategies and behaviors directed at individuals with ASD.

**Keywords:** Autism Spectrum Disorder, knowledge, lay beliefs, survey

### **1. Introduction**

Autism Spectrum Disorders (ASDs) constitute a group of disorders characterized by changes present at early ages and manifesting in the areas of development of communication, behavior, and interpersonal relationship. Early diagnosis and intervention are essential for the prognosis [1]. The Centers for Disease Control and Prevention (CDC) estimate the prevalence

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

of ASD to be 1 in 68 children [2]. The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) [3], provides criteria to diagnose ASD. The two sets of criteria involved are related to social communication deficits and restricted, repetitive patterns of behavior, interests, or activities. The social and language difficulties characteristic of ASD make the speech therapist participation indispensable in any action for ASD.

This premise originated a study [15] that had for its purpose the elaboration and application of an online questionnaire to know what the consolidated information that the Brazilian population has on the subject of autism. A total of 5000 people answered the survey of whom

Information and Impression Regarding ASD Questionnaire Answered by Foreigners Living in Brazil

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139

The participation of foreigners was not predicted by the study. None of the instruments used (invitation, questionnaire, and instructions) were elaborated in another language or with any additional resources that facilitated the participation of nonfluent citizens in Portuguese. As the participation of foreigners was not objective of the study, the information collected from the participants did not contemplate sufficient data to characterize the foreign participants. However, the spontaneous participation of 657 foreigners (13% of all study participants) reveals the urgent need to understand the particularities of this population and establish pro-

The present study aims to present the results of this group of foreigners, considering the par-

Immigration is an important phenomenon all over the world today. The results described in this chapter involve the participation of professionals and family members of children with ASD from 23 different countries. This certainly helps to increase the knowledge of how much this population has of information and impression regarding ASD. This better characterization and understanding becomes paramount for the different realities of countries that receive

An authorization was obtained from the Ethics Committee for Research of the host institution (protocol number: 954.385), which authorized the study and agreed with the request to waive

A total of 657 people participated in this study, who were willing to respond to a digital questionnaire composed of closed questions written in Portuguese. These people were contacted to participate in the survey by invitation received by e-mail or by publication in social network. The two invitations were also written in Portuguese. Each participant could forward the invitation to whom it considered pertinent. There was no way to identify the respondent or the device used to complete the questionnaire. As there was an exemption from the consent form, only completed questionnaires were considered, with the understanding that if the person answered all the questions and sent the answers she agreed to participate in the study. Completion of the questionnaire was done only in digital media because it was part of the study to consider the efficiency of this medium as a

A total of 4600 e-mails were sent per month at regular intervals throughout the 18-month period in which the questionnaire was available on the web. During this period, there was

also 1 weekly publication in social networks, inviting to participate in the study.

ticularities and importance in the deepening of the reflection at world level.

657 were foreign residents in Brazil.

posals for specific attention and care for them.

any kind of immigration phenomena.

the use of the free and informed consent term.

**2. Methods**

research tool.

Studies on language in ASD highlight that the greatest difficulty of these individuals is related to the functional use of language. Language skills are certainly the greatest perceived difficulties in individuals with ASD [4].

The pragmatic aspects of language involve specific communication skills, deficits in nonverbal communication, and difficulties adjusting behavior according to various social contexts, which includes language adjustment for different listeners. The characterization of language in the pragmatic perspective considers the relationship established between interlocutors, the communicative context, and the sociocultural elements involved [5].

For the communication to be effective, the interlocutor must be able to use the language in each situation appropriately, to understand social cues used in each context. This pragmatic competence includes verbal and nonverbal communication skills, besides considering the social understanding and the communicative context in which the communicative exchanges are carried out [5, 6].

Because ASD significantly affects communication and the social skills, all multicultural context needs to be better investigated. There is an urgent need to understand the impact of migratory process, bilingual environment exposure on the language development of children with ASDs.

In recent years, the world has experienced a great migratory movement. In 2015, the Department of Economic and Social Affairs (UN DESA) [7] registered the mark of 244 million international immigrants, an increase of 41% over the year 2000. The number of immigrants totaled 3.3% of the global population in 2015, while in 2000, they totaled 2.8%.

Some studies have pointed out the importance of investigating autism in an international setting considering all the cultural, social, and language implications involved in a migratory process [8–11].

Within this scenario, Brazil is characterized as a country of continental dimensions, with a territory of more than 8 million km2 and with an estimated population of more than 206 million inhabitants. Many are the indexes that point to the existing inequality within the country as well as to the difficulties imposed by its size and diversity. Faced with this reality, there are very few population data, especially in terms of communication aspects, as well as access to specialized assessment and intervention programs. However, it is possible to know that just as in the world Brazil has also received many international immigrants. In 2015, there were 1,847,274 regular immigrants according to the statistics of the Brazilian Federal Police [12].

Cultural, social, and linguistic diversity needs to be considered when focusing on ASD diagnosis and intervention. Therefore, systematized research regarding the degree of knowledge and information that the population has about autism can contribute to the construction of a body of evidence that bases the decision making regarding proposals of intervention directed to those with ASD [13, 14].

This premise originated a study [15] that had for its purpose the elaboration and application of an online questionnaire to know what the consolidated information that the Brazilian population has on the subject of autism. A total of 5000 people answered the survey of whom 657 were foreign residents in Brazil.

The participation of foreigners was not predicted by the study. None of the instruments used (invitation, questionnaire, and instructions) were elaborated in another language or with any additional resources that facilitated the participation of nonfluent citizens in Portuguese. As the participation of foreigners was not objective of the study, the information collected from the participants did not contemplate sufficient data to characterize the foreign participants. However, the spontaneous participation of 657 foreigners (13% of all study participants) reveals the urgent need to understand the particularities of this population and establish proposals for specific attention and care for them.

The present study aims to present the results of this group of foreigners, considering the particularities and importance in the deepening of the reflection at world level.

Immigration is an important phenomenon all over the world today. The results described in this chapter involve the participation of professionals and family members of children with ASD from 23 different countries. This certainly helps to increase the knowledge of how much this population has of information and impression regarding ASD. This better characterization and understanding becomes paramount for the different realities of countries that receive any kind of immigration phenomena.

### **2. Methods**

of ASD to be 1 in 68 children [2]. The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) [3], provides criteria to diagnose ASD. The two sets of criteria involved are related to social communication deficits and restricted, repetitive patterns of behavior, interests, or activities. The social and language difficulties characteristic of ASD make the speech therapist participa-

Studies on language in ASD highlight that the greatest difficulty of these individuals is related to the functional use of language. Language skills are certainly the greatest perceived difficul-

The pragmatic aspects of language involve specific communication skills, deficits in nonverbal communication, and difficulties adjusting behavior according to various social contexts, which includes language adjustment for different listeners. The characterization of language in the pragmatic perspective considers the relationship established between interlocutors, the

For the communication to be effective, the interlocutor must be able to use the language in each situation appropriately, to understand social cues used in each context. This pragmatic competence includes verbal and nonverbal communication skills, besides considering the social understanding and the communicative context in which the communicative exchanges are carried out [5, 6]. Because ASD significantly affects communication and the social skills, all multicultural context needs to be better investigated. There is an urgent need to understand the impact of migratory process, bilingual environment exposure on the language development of children with ASDs. In recent years, the world has experienced a great migratory movement. In 2015, the Department of Economic and Social Affairs (UN DESA) [7] registered the mark of 244 million international immigrants, an increase of 41% over the year 2000. The number of immigrants

Some studies have pointed out the importance of investigating autism in an international setting considering all the cultural, social, and language implications involved in a migratory

Within this scenario, Brazil is characterized as a country of continental dimensions, with a ter-

inhabitants. Many are the indexes that point to the existing inequality within the country as well as to the difficulties imposed by its size and diversity. Faced with this reality, there are very few population data, especially in terms of communication aspects, as well as access to specialized assessment and intervention programs. However, it is possible to know that just as in the world Brazil has also received many international immigrants. In 2015, there were 1,847,274 regular immigrants according to the statistics of the Brazilian Federal Police [12].

Cultural, social, and linguistic diversity needs to be considered when focusing on ASD diagnosis and intervention. Therefore, systematized research regarding the degree of knowledge and information that the population has about autism can contribute to the construction of a body of evidence that bases the decision making regarding proposals of intervention directed

and with an estimated population of more than 206 million

communicative context, and the sociocultural elements involved [5].

totaled 3.3% of the global population in 2015, while in 2000, they totaled 2.8%.

tion indispensable in any action for ASD.

ties in individuals with ASD [4].

138 Advances in Speech-language Pathology

process [8–11].

ritory of more than 8 million km2

to those with ASD [13, 14].

An authorization was obtained from the Ethics Committee for Research of the host institution (protocol number: 954.385), which authorized the study and agreed with the request to waive the use of the free and informed consent term.

A total of 657 people participated in this study, who were willing to respond to a digital questionnaire composed of closed questions written in Portuguese. These people were contacted to participate in the survey by invitation received by e-mail or by publication in social network. The two invitations were also written in Portuguese. Each participant could forward the invitation to whom it considered pertinent. There was no way to identify the respondent or the device used to complete the questionnaire. As there was an exemption from the consent form, only completed questionnaires were considered, with the understanding that if the person answered all the questions and sent the answers she agreed to participate in the study. Completion of the questionnaire was done only in digital media because it was part of the study to consider the efficiency of this medium as a research tool.

A total of 4600 e-mails were sent per month at regular intervals throughout the 18-month period in which the questionnaire was available on the web. During this period, there was also 1 weekly publication in social networks, inviting to participate in the study.

The questionnaire was self-explanatory allowing to be answered in an autonomous way. The instrument contained five parts, the first involved information about the participant. The second block of questions sought to know if the participant already had some contact with the topic autism and how was given this contact. The third part of the instrument addressed the participant's knowledge about the etiology, signs, and symptoms of autism. The fourth part of the instrument sought to investigate the participant's knowledge about the variability of the symptoms of individuals with ASD. The last part of the questionnaire had as an objective to know from the perception of the participant which professionals are essential for the monitoring of the autistic individual.

All study participants attended school. The majority completed higher education (25.9%) and

Participants from 23 countries responded to the survey. Bolivia and Argentina were the coun-

Elementary school 85 13.0 Complete primary education 120 18.3 High school 122 18.5 Incomplete higher education 132 20.0 Complete higher education 170 **25**.**9** Postgraduate studies 28 4.3

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tries with the highest number of participants (17.2 and 14.8%, respectively) (**Table 3**).

**Level of education Classification** *N* **%**

**Country of origin** *N* **%** Bolivia 113 **17**.**2** Argentina 97 **14**.**8** Japan 79 12.0 China 54 8.2 Colombia 43 6.5 USA 37 5.6 Paraguay 33 5.0 Uruguay 29 4.4 Netherlands 28 4.3 Jordan 24 3.7 Lebanon 20 3.0 Spain 19 2.9 Haiti 16 2.4 Portugal 14 2.2 Greece 11 1.7 Italy 11 1.7 Peru 9 1.4 Indonesia 8 1.2 Germany 7 1.1 Belgium 2 0.3 Israel 1 0.2 Cuba 1 0.2 Chile 1 0.2

*Note:* The data marked in bold represent the most frequent occurrences

**Table 3.** The country of origin of the 657 participants.

the smallest part had postgraduation (4.3%) (**Table 2**).

*Note:* The data marked in bold represent the most frequent occurrences

**Table 2.** Level of education of the 657 participants.

Of the 5000 completed questionnaires, only 657 were considered for this study because they were answered by non-Brazilian citizens.

### **3. Results**

### **3.1. Sociodemographic profile**

The predominant age group of the participants was between 30 and 39 years of age, of the feminine gender, and of the race declared as white. The informant family income was between R\$1000.00 and R\$3000.00—equivalent to US\$ 300.00 and 900.00 per month (**Table 1**).

**Table 1.** Description of the 657 participants in the study.

All study participants attended school. The majority completed higher education (25.9%) and the smallest part had postgraduation (4.3%) (**Table 2**).

Participants from 23 countries responded to the survey. Bolivia and Argentina were the countries with the highest number of participants (17.2 and 14.8%, respectively) (**Table 3**).

**Table 2.** Level of education of the 657 participants.

The questionnaire was self-explanatory allowing to be answered in an autonomous way. The instrument contained five parts, the first involved information about the participant. The second block of questions sought to know if the participant already had some contact with the topic autism and how was given this contact. The third part of the instrument addressed the participant's knowledge about the etiology, signs, and symptoms of autism. The fourth part of the instrument sought to investigate the participant's knowledge about the variability of the symptoms of individuals with ASD. The last part of the questionnaire had as an objective to know from the perception of the participant which professionals are essential for

Of the 5000 completed questionnaires, only 657 were considered for this study because they

The predominant age group of the participants was between 30 and 39 years of age, of the feminine gender, and of the race declared as white. The informant family income was between

> 30–39 years old 256 **39**.**0** 40–49 years old 146 22.1 50–59 years old 34 5.2 Over 60 years old 13 2.0

> Female 552 **84**.**0**

Yellow 105 16.0 Brown 96 14.6 Black 36 5.5 Indigenous 10 1.5

Between US\$300 and US\$900 226 **34**.**4** Between US\$900 and US\$1800 177 26.9 More than US\$1800 57 8.7 Did not know 0 0.0 Was not able to inform 108 16.5

R\$1000.00 and R\$3000.00—equivalent to US\$ 300.00 and 900.00 per month (**Table 1**).

**Demographic information Classification** *N* **%** Age group 18–29 years old 208 31.7

Genre Male 105 16.0

Race White 410 **62**.**4**

Monthly household income Less than US\$300 89 13.5

*Note:* The data marked in bold represent the most frequent occurrences

**Table 1.** Description of the 657 participants in the study.

the monitoring of the autistic individual.

were answered by non-Brazilian citizens.

**3.1. Sociodemographic profile**

140 Advances in Speech-language Pathology

**3. Results**

*Note:* The data marked in bold represent the most frequent occurrences

**Table 3.** The country of origin of the 657 participants.

### **3.2. Information about how the participant had access to the topic autism**

All participants knew the term "autism" (100%). Most of them have an autistic individual in the family (87.8%) (**Tables 4** and **5**).

**Knowledge about autism Yes No**

*Note:* The data marked in bold represent the most frequent occurrences

**Specific characteristics All Many Some None**

Isolation 361 55 158 24.1 43 6.5 5 0.9 Aggressive behaviors 66 10.4 183 27.85 251 38.2 157 23.89 Difficulty in social life 93 14.15 426 64.84 138 21 0 0 Do not make eye contact 154 23.43 207 31.5 152 23.13 144 21.91 Do not talk 257 39.11 354 53.88 36 5.47 10 1.52 Eye contact changed 216 32.87 194 29.52 158 24.04 22 3.34 Difficulty in communicating 507 77.16 134 20.39 16 2.43 0 0 Specific physical characteristics 150 22.83 4 0.6 3 0.45 410 62.4 Intellectual deficit 121 18,41 267 40.63 154 23.43 25 3.8

*N* **%** *N* **%** *N* **%** *N* **%**

**Table 6.**

Is autism a disability? 427 65 230 35 Is autism a psychological state? 105 16 552 84 Is autism a social condition? 265 40.3 392 59.7 Is autism a disease? 321 48.9 336 51.1 Is autism an illness that you are born with? 287 43.7 370 56.3 Does autism have genetic origin? 81 12.3 576 87.7 Is autism hereditary? Do you move from a mother/father to a child? 67 10.1 590 89.9 Does autism have a cure? 390 59.4 267 40.6 Is autism contagious? 21 **3**.**2** 636 96.8 Is autism a rare disease? 104 15.8 553 84.2 Is autism an acquired illness? 227 34.5 430 65.5 Are there different types of autism? 301 45.8 356 54.2 Environmental factors cause autism? 157 23.9 500 76.1 Are there medications for autism? 201 30.6 456 69.4 Is there an exam that detects autism? 97 14.8 560 85.2 Is the cause of autism known? 147 22.4 510 77.6 Is the cause of autism determined? 169 25.7 488 74.3 Is autism a consequence of emotional trauma? 187 28.5 470 71.5 Is autism a developmental disorder? 301 45.8 356 54.2 Vaccine causes autism? 294 44.7 363 55.3

Information and Impression Regarding ASD Questionnaire Answered by Foreigners Living in Brazil

*N* **%** *N* **%**

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143

### **3.3. Information about what the participant knew about autism**

The answers given to questions about the participant's knowledge about autism were categorized (**Table 6**). The percentage of occurrence was less than 10% only in the question about the contagion, and in seven questions, the answers were between 40 and 50% (**Table 7**).

### **3.4. Information about what the participant identifies as specific characteristics of an autistic person**

The highest concordances as to the characteristics of autistic individuals are the difficulties of communication (77.2%) and do not answer to the name when called (74.1%) (**Table 7**).

### **3.5. Information on what professionals are indispensable for the care of an autistic individual**

The professionals who presented the highest concordance as essential for the treatment of an autistic individual were: Neurologist (98.9%), Neuropediatrician (96.5%), Specialized Teacher (89.3%), Psychiatrist (89.3%), and Speech therapist (85.8%) (**Table 8**).

*Note:* The data marked in bold represent the most frequent occurrences

**Table 4.** Means of access to the autism theme of the 657 participants.

**Table 5.** How the contact with the autistic individual occurred by the 657 participants.

*Note:* The data marked in bold represent the most frequent occurrences

**Table 6.**  Information about how the participant had access to the topic autism**

**3.3. Information about what the participant knew about autism**

the family (87.8%) (**Tables 4** and **5**).

142 Advances in Speech-language Pathology

**autistic person**

**individual**

All participants knew the term "autism" (100%). Most of them have an autistic individual in

The answers given to questions about the participant's knowledge about autism were categorized (**Table 6**). The percentage of occurrence was less than 10% only in the question about the

The highest concordances as to the characteristics of autistic individuals are the difficulties of

The professionals who presented the highest concordance as essential for the treatment of an autistic individual were: Neurologist (98.9%), Neuropediatrician (96.5%), Specialized Teacher

contagion, and in seven questions, the answers were between 40 and 50% (**Table 7**).

**3.4. Information about what the participant identifies as specific characteristics of an**

communication (77.2%) and do not answer to the name when called (74.1%) (**Table 7**).

**3.5. Information on what professionals are indispensable for the care of an autistic**

(89.3%), Psychiatrist (89.3%), and Speech therapist (85.8%) (**Table 8**).

**Means of access** *N* **%** TV 87 13.2 Desktop 116 17.7 Family 577 **87**.**8** Website 398 60.6

**Means of contact** *N* **%** Mother 343 **52**.**2** Father 72 11.0 Family 114 17.4 Professional 128 19.5

**Table 5.** How the contact with the autistic individual occurred by the 657 participants.

*Note:* The data marked in bold represent the most frequent occurrences

*Note:* The data marked in bold represent the most frequent occurrences

**Table 4.** Means of access to the autism theme of the 657 participants.

**4. Discussion**

questionnaire.

this study [19].

The study involved participants from 23 countries. Among the 23 countries, 10 countries are Spanish-speaking or Portuguese speaking, and 13 countries with more different languages, such as Greece, Lebanon, and Jordan. Unfortunately, the study did not provide information on participants' level of proficiency in Portuguese. Therefore, it is only possible to suppose that participants from Spanish-speaking countries had less difficulty answering the questionnaire than participants from countries with languages more distant from Portuguese. Another hypothesis to be considered is the possibility of participants using a digital tool as a resource

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145

The present study found that 100% of the participants have heard of autism, and the level of autism awareness can be considered as high. The high level of awareness reported in the present study reflected the fact that 80.6% of the sample had a family member with autism. Women (84%) and mothers (52.2%) of autistic children mainly answered the questionnaire. These data suggest that the care of children with ASD is still responsibility of women, moth-

Another aspect to be considered is the high level of education of the participants. This fact should have contributed to the study access and the possibility of responding to the

The low family income declared by the participants points to possible difficulties faced by

Generally, the immigration process involves difficulties for social, school, and work adaptation. These difficulties can be hard hit by the presence of an autistic child who requires more

Many studies have investigated the information that the general population or specific groups have about autism. The autism knowledge in a health care setting [16], experiences of autism diagnosis [17], lay beliefs, and the role of cultural values [18]. A general population survey assessed autism awareness, knowledge about autism, and perceptions about autism interventions in Northern Ireland using a digital instrument and had similar results to those found in

Other studies investigating language aspects of autistic children in bilingual [20–23], multicultural environments [24, 25], specifically with minority groups [26], of immigrants [27] reported aspects like those observed in this study. One study [10] was found that involved research into

The great migratory movement observed worldwide reflects in the growing ethnic and cultural diversity of the Brazilian population. This reality brings new challenges for professionals working in the field of health and education. Based on what is already happening in other countries [25], it is necessary to establish public proposals that guarantee the access of this population to basic services through culturally appropriate strategies. Specifically, the speech

care and closer and systematic follow-up in social and communication situations.

autism awareness and knowledge about autism specifically in foreigners.

to translate the questionnaire into their native language.

ers, and professionals working with children with ASD.

foreigners, difficulties in adapting to different realities and culture.

**Table 7.**

**Table 8.** Professionals essential to care for an autistic person.

### **4. Discussion**

**Specific characteristics All Many Some None**

Absence of affection, affection for

144 Advances in Speech-language Pathology

decontextualized words (echolalia)

Can be independent, take over the

**Table 7.**

*Note:* The data marked in bold represent the most frequent occurrences

**Table 8.** Professionals essential to care for an autistic person.

**Essential professional** *N* **%** Neurologist 650 **98**.**9** Neuropediatrician 634 **96**.**5** Specialized teacher 587 **89**.**3** Psychiatrist 587 **89**.**3** Speech therapist 564 **85**.**8** Pediatrician 509 77.5 Psychologist 460 70.0 Psychopedagogue 398 60.6 Nutritionist 354 53.9 Occupational therapist 325 49.5 Psychomotrist 201 30.6 Physical educator 125 19.0 Geneticist 109 16.6 Physiotherapist 107 16.3 Dentist 0 0.0

Behavior of waving, swinging,

Repetition of phrases,

conduct of one's life

turning, or staring

anyone

Special skills 132 20.09 232 35.31 187 28.46 106 16.13 Sleep disorders 60 9.13 163 24.8 69 10.5 365 55.55 Hearing compromised 29 4.41 110 16.74 320 48.7 198 30.13 Food difficulties 14 2.13 321 48.85 292 44.44 30 4.56 Visual impairments 170 25.87 0 0 0 0 487 74.12 Respiratory distress 28 4.26 160 24.35 0 0 469 71.38 Difficulty playing 187 28.46 274 41.7 196 29.83 0 0 No response when called by name 487 74.12 0 0 20 3.04 150 22.83

*N* **%** *N* **%** *N* **%** *N* **%**

39 5.93 204 31.05 287 43.68 127 19.33

150 22.83 150 22.83 205 31.2 152 23.13

63 9.58 143 21.76 152 23.13 299 45.5

354 53.88 8 1.21 11 1.67 284 43.22

The study involved participants from 23 countries. Among the 23 countries, 10 countries are Spanish-speaking or Portuguese speaking, and 13 countries with more different languages, such as Greece, Lebanon, and Jordan. Unfortunately, the study did not provide information on participants' level of proficiency in Portuguese. Therefore, it is only possible to suppose that participants from Spanish-speaking countries had less difficulty answering the questionnaire than participants from countries with languages more distant from Portuguese. Another hypothesis to be considered is the possibility of participants using a digital tool as a resource to translate the questionnaire into their native language.

The present study found that 100% of the participants have heard of autism, and the level of autism awareness can be considered as high. The high level of awareness reported in the present study reflected the fact that 80.6% of the sample had a family member with autism. Women (84%) and mothers (52.2%) of autistic children mainly answered the questionnaire. These data suggest that the care of children with ASD is still responsibility of women, mothers, and professionals working with children with ASD.

Another aspect to be considered is the high level of education of the participants. This fact should have contributed to the study access and the possibility of responding to the questionnaire.

The low family income declared by the participants points to possible difficulties faced by foreigners, difficulties in adapting to different realities and culture.

Generally, the immigration process involves difficulties for social, school, and work adaptation. These difficulties can be hard hit by the presence of an autistic child who requires more care and closer and systematic follow-up in social and communication situations.

Many studies have investigated the information that the general population or specific groups have about autism. The autism knowledge in a health care setting [16], experiences of autism diagnosis [17], lay beliefs, and the role of cultural values [18]. A general population survey assessed autism awareness, knowledge about autism, and perceptions about autism interventions in Northern Ireland using a digital instrument and had similar results to those found in this study [19].

Other studies investigating language aspects of autistic children in bilingual [20–23], multicultural environments [24, 25], specifically with minority groups [26], of immigrants [27] reported aspects like those observed in this study. One study [10] was found that involved research into autism awareness and knowledge about autism specifically in foreigners.

The great migratory movement observed worldwide reflects in the growing ethnic and cultural diversity of the Brazilian population. This reality brings new challenges for professionals working in the field of health and education. Based on what is already happening in other countries [25], it is necessary to establish public proposals that guarantee the access of this population to basic services through culturally appropriate strategies. Specifically, the speech therapist must improve instruments and procedures that are efficient to distinguish what is characteristic of social adaptation, which is part of the heritage of culture, the native language, and what is really a communication disorder.

**Author details**

de Andrade Varanda3

**References**

**23**(1):1-7

Cibelle Albuquerque de la Higuera Amato1

2 Universidade de São Paulo, São Paulo, Brazil

3 Universidade Paulista, Santos, Brazil

\*Address all correspondence to<EMAIL_ADDRESS>1 Universidade Presbiteriana Mackenzie, São Paulo, Brazil

\*, Daniela Regina Molini-Avejonas2

Information and Impression Regarding ASD Questionnaire Answered by Foreigners Living in Brazil

[1] Fernandes FDM, Amato CAH, Defense-Netvral DA, Balestro JI, Molini-Avejonas DR. Addressing Communication Difficulties of Parents of Children of the Autism Spectrum, Recent Advances in Autism Spectrum Disorders—Volume I, Fitzgerald M, editor. Croatia, InTech; 2013. DOI: 10.5772/53964. Available from: https://www. intechopen.com/books/recent-advances-in-autism-spectrum-disorders-volume-i/ addressing-communication-difficulties-of-parents-of-children-of-the-autism-spectrum

[2] Centers for Disease Control and Prevention (CDC). Prevalence of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2010 (MMWR No. 63-SS02); 2014. Retrieved from http://

[3] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,

[4] Fernandes FDM, et al. Orientação a mães de crianças do espectro autístico a respeito da comunicação e linguagem. Jornal da Sociedade Brasileira de Fonoaudiologia. 2011;

[5] Westby C. Social-emotional bases of pragmatic and communication development In: Singleton NC, Shulman BB. Language Development—Foundations, Processes and

[6] Riquelme LF, Rosas J. Multicultural perspectives: The road to cultural competence. In: Singleton NC, Shulman BB. Language Development—Foundations, Processes and

[7] United Nations, Department of Economic and Social Affairs, Population Division. International Migration Report 2015: Highlights (ST/ESA/SER.A/375); 2016. Retrieved from http://www.un.org/en/development/desa/population/migration/publications/

5th ed. (DSM-V). Arlington, VA: American Psychiatric Association; 2013

Clinical Applications. EUA, Jones & Bartlett Learning; 2010. pp. 119-146

Clinical Applications. EUA, Jones & Bartlett Learning; 2010. pp. 231-249

migrationreport/docs/MigrationReport2015\_Highlights.pdf

www.cdc.gov/mmwr/preview/mmwrhtml/ss6302a1.htm

and Cristina

147

http://dx.doi.org/10.5772/intechopen.70397

About ASD, it is necessary to ensure that all children have equal access to quality and early diagnosis. Speech-language assessment should be sensitive enough to distinguish cultural differences from communication disorders characteristic of ASD.

The speech pathologist has a responsibility to enhance knowledge about the social media profile characteristic of ASD, to strengthen information about the initial characteristics of ASD, and to improve early detection. The speech therapist should engage in the dissemination and awareness of the ASD by strengthening access to information and care for all by reducing social disparities.

### **5. Conclusion**

The sociodemographic diversity identified in this study reflects the sociocultural diversity present in Brazil, besides reinforcing the importance of considering this population when thinking about strategies and behaviors directed at individuals with ASD. It is important to emphasize that all participants in the research were linked to people with autism or family ties or working with this population.

Since it was not the focus of the original study, it is not possible to know the exact situation of foreigners in Brazil, whether they are temporary workers, residents, or refugees. The fact is that regardless of the condition in which these people meet, the unique condition of the ASD mobilizes them to seek information and help. In this sense, the Internet becomes a very important tool because it allows reducing the sociocultural and linguistic distances that can so much impact the acquaintanceship of these people.

Social isolation and stigmatization may be intensified by economic, social, and linguistic difficulties in addition to limited awareness of autism.

Regardless of the condition of life, parents play a crucial role in the early identification and treatment of ASD. Their cultural beliefs about development and disability can influence the proximal processes and decisions about caring for their children.

Care must be taken to ensure that situations experienced by foreigners, such as social isolation, language difficulties, cultural diversity do not interfere with the diagnosis of ASD.

### **Acknowledgements**

This project was supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

### **Author details**

therapist must improve instruments and procedures that are efficient to distinguish what is characteristic of social adaptation, which is part of the heritage of culture, the native language,

About ASD, it is necessary to ensure that all children have equal access to quality and early diagnosis. Speech-language assessment should be sensitive enough to distinguish cultural

The speech pathologist has a responsibility to enhance knowledge about the social media profile characteristic of ASD, to strengthen information about the initial characteristics of ASD, and to improve early detection. The speech therapist should engage in the dissemination and awareness of the ASD by strengthening access to information and care for all by reducing

The sociodemographic diversity identified in this study reflects the sociocultural diversity present in Brazil, besides reinforcing the importance of considering this population when thinking about strategies and behaviors directed at individuals with ASD. It is important to emphasize that all participants in the research were linked to people with autism or family

Since it was not the focus of the original study, it is not possible to know the exact situation of foreigners in Brazil, whether they are temporary workers, residents, or refugees. The fact is that regardless of the condition in which these people meet, the unique condition of the ASD mobilizes them to seek information and help. In this sense, the Internet becomes a very important tool because it allows reducing the sociocultural and linguistic distances that can

Social isolation and stigmatization may be intensified by economic, social, and linguistic dif-

Regardless of the condition of life, parents play a crucial role in the early identification and treatment of ASD. Their cultural beliefs about development and disability can influence the

Care must be taken to ensure that situations experienced by foreigners, such as social isolation, language difficulties, cultural diversity do not interfere with the diagnosis of ASD.

This project was supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico

and what is really a communication disorder.

146 Advances in Speech-language Pathology

social disparities.

**5. Conclusion**

ties or working with this population.

**Acknowledgements**

(CNPq).

so much impact the acquaintanceship of these people.

ficulties in addition to limited awareness of autism.

proximal processes and decisions about caring for their children.

differences from communication disorders characteristic of ASD.

Cibelle Albuquerque de la Higuera Amato1 \*, Daniela Regina Molini-Avejonas2 and Cristina de Andrade Varanda3

### **References**

[8] Siller M, Morgan L, Swanson M, Hotez E. Promoting Early Identification of Autism in the Primary Care Setting: Bridging the Gap Between What We Know and What We Do, Recent Advances in Autism Spectrum Disorders—Volume I, Fitzgerald M, editor. Croatia, InTech; 2013. DOI: 10.5772/53715. Available from: https://www.intechopen. com/books/recent-advances-in-autism-spectrum-disorders-volume-i/promoting-earlyidentification-of-autism-in-the-primary-care-setting-bridging-the-gap-between-what-w

[20] Lund EM, Kohlmeier TL, Durán LK. Comparative language development in bilingual and monolingual children with Autism Spectrum Diosrder: A Systematic Review.

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[21] Petersen J, Marinova-Todd SH, Mirenda P. An exploratory study of lexical skills in bilingual children with Autism Spectrum Disorder. Journal of Autism and Developmental

[22] Hambly C, Fombonne E. The impact of bilingual environments on language development in children with autism spectrum disorders. Journal of Autism and Developmental

[23] Kohnert K, Yim D, Nett K, Kan PF, Duran L. Intervention with linguistically diverse preschool children: A focus on developing home languages(s). Language, Speech and

[24] Winsler A, Burchinal MR, Tien H-C. Early development among dual language learners: The roles of language use at home, maternal immigration, country of origin, and socio-

[25] Stronacha ST, Wetherby AM. Observed and parent-report measures of social communication in toddlers with and without Autism Spectrum Disorder across race/ethnicity.

[26] Yua B. Issues in bilingualism and heritage language maintenance: Perspectives of minority-language mothers of children with Autism Spectrum Disorders. American Journal of

[27] Reetzke R, Zou X, Sheng L, Katsosb N. Communicative development in bilingually exposed Chinese Children with Autism Spectrum Disorders. Journal of Speech,

demographic variables. Early Child Research Quaterly. 2014;**29**(4):750-764

American Journal of Speech-Language Pathology. 2017;**26**:355-368

Journal of Early Intervention. 2017;**39**(2):106-124

Hearing Services in Schools. 2005;**36**:251-263

Speech-Language Pathology. 2013;**22**:10-24

Language, and Hearing Research. 2015;**58**:813-825

Disorders. 2012;**42**(7):1499-1503

Disorders. 2012;**42**(7):1342-1352

[20] Lund EM, Kohlmeier TL, Durán LK. Comparative language development in bilingual and monolingual children with Autism Spectrum Diosrder: A Systematic Review. Journal of Early Intervention. 2017;**39**(2):106-124

[8] Siller M, Morgan L, Swanson M, Hotez E. Promoting Early Identification of Autism in the Primary Care Setting: Bridging the Gap Between What We Know and What We Do, Recent Advances in Autism Spectrum Disorders—Volume I, Fitzgerald M, editor. Croatia, InTech; 2013. DOI: 10.5772/53715. Available from: https://www.intechopen. com/books/recent-advances-in-autism-spectrum-disorders-volume-i/promoting-earlyidentification-of-autism-in-the-primary-care-setting-bridging-the-gap-between-what-w

[9] Crafa D. Migration and Autism Diagnosis, Autism—Paradigms, Recent Research and Clinical Applications. Fitzgerald M, editor. InTech; 2017. DOI: 10.5772/65981. Retrieved from: https://www.intechopen.com/books/autism-paradigms-recent-research-and-clini-

[10] Ijalba E. Hispanic immigrant mothers of young children with Autism Spectrum Disorders: How do they understand and cope with autism? American Journal of Speech-Language Pathology. 2016 May;**25**:200-213. Retrieved from: http://ajslp.pubs.asha.org

[11] Stronach ST, Wetherby AM. Observed and Parent-Report measures of social communication in Toddlers with and without Autism Spectrum Disorder across Race/Ethnicity. American Journal of Speech-Language Pathology. 2017 May;**26**:355-368. Retrieved from:

[12] Brasil. Departamento de Migrações da Secretaria Nacional de Justiça e Cidadania

[13] Keen D, Rodger S, Doussin K, Braithwaite M. A pilot study of the effects of a social-pragmatic intervention on the communication and symbolic play of children with autism.

[14] Sutera A, Pandey J, Esser EL, Rosenthal MA, Wilson LB, Barton M, et al. Predictors of optimal outcome in toddlers diagnosed with autism spectrum disorders. Journal of

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[16] Heidgerken AD, Geffken G, Modi A, Frakey L. A survey of autism knowledge in a health care setting. Journal of Autism and Developmental Disorders. 2015;**35**(3):323-330

[17] Crane L, Chester JW, Goddard L, Henry LA, Hill E. Experience of autism diagnosis: A survey of over 1000 parents in the United Kingdom. Autism. 2016;**20**(2):153-162

[18] Qi X, Zaroff CM, Bernardo AB. Autism spectrum disorder etiology: Lays beliefs and the

[19] Dillenburger K, Jordan JA, McKerr L, Devine P, Keenan M. Awareness and knowledge of autism and autism interventions: A general population survey. Research in Autism

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148 Advances in Speech-language Pathology

ahead of print

cal-applications/migration-and-autism-diagnosis

**Chapter 9**

**Comparison of the Results of Token Test and Sentence**

**Comprehension Test in Pre‐school Czech Children with**

27 pre-school (26 native Czech-speaking and 1 native Russian-speaking) children (age 4; 6–7; 9 and gender 18 m; 9 f); 17 children with speech and language disorders from speech and language kindergarten (SLK) and 10 children with typical language development (TLD) from a kindergarten of common type, received two tests of language comprehension, the Token Test (TT) and the subtest from the Heidelberg Language Development Test (H-S-E-T) called The Sentence Comprehension Test (SCT). The results of the TT (success rate of children with TLD was 77%; children from SLK scored 70%) surpassed the results of the SCT (children with TLD 59%; children from SLK 44%) in both groups. The most severe deficiencies have been observed in children with SLI and a boy with severe bilateral sensorineural hearing loss. The observed differences between the means in both groups (TLD, *N* = 10; SLD, *N* = 17) were not statistically significant, using Student's t-test (TT, *p* = 0.28; SCT, *p* = 0.11). There were not statistically significant differences between the means in children from three compared groups (TLD, *N* = 10; SLI, *N* = 8; articulation

disorders, *N* = 6), using the ANOVA (TT, *p* = 0.60; SCT, *p* = 0.23).

**Keywords:** specific language impairment, comprehension, language disorders

This paper focuses on understanding sentences communicated via oral speech in pre-school children. As reported by Smolík and Seidlová-Málková [1], only grammatical knowledge can help a child in recognizing different meanings of phrases, such as *"A cat chases a dog"* and

> © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Typical Language Development and with Speech‐**

**Language Disorders**

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69709

Renata Mlčáková

**Abstract**

**1. Introduction**

**Comparison of the Results of Token Test and Sentence Comprehension Test in Pre‐school Czech Children with Typical Language Development and with Speech‐ Language Disorders**

### Renata Mlčáková

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69709

### **Abstract**

27 pre-school (26 native Czech-speaking and 1 native Russian-speaking) children (age 4; 6–7; 9 and gender 18 m; 9 f); 17 children with speech and language disorders from speech and language kindergarten (SLK) and 10 children with typical language development (TLD) from a kindergarten of common type, received two tests of language comprehension, the Token Test (TT) and the subtest from the Heidelberg Language Development Test (H-S-E-T) called The Sentence Comprehension Test (SCT). The results of the TT (success rate of children with TLD was 77%; children from SLK scored 70%) surpassed the results of the SCT (children with TLD 59%; children from SLK 44%) in both groups. The most severe deficiencies have been observed in children with SLI and a boy with severe bilateral sensorineural hearing loss. The observed differences between the means in both groups (TLD, *N* = 10; SLD, *N* = 17) were not statistically significant, using Student's t-test (TT, *p* = 0.28; SCT, *p* = 0.11). There were not statistically significant differences between the means in children from three compared groups (TLD, *N* = 10; SLI, *N* = 8; articulation disorders, *N* = 6), using the ANOVA (TT, *p* = 0.60; SCT, *p* = 0.23).

**Keywords:** specific language impairment, comprehension, language disorders

### **1. Introduction**

This paper focuses on understanding sentences communicated via oral speech in pre-school children. As reported by Smolík and Seidlová-Málková [1], only grammatical knowledge can help a child in recognizing different meanings of phrases, such as *"A cat chases a dog"* and

*"A cat is chased by a dog."* We decided to observe the issue of understanding oral speech in pre-school children because it far exceeds school education and offers new areas for research exploration. School work is imbued with permanently working with a given language in the area of reception (understanding) and expression (production)—in the speaking, reading and written forms. In some cases, pre-school children who face difficulties in understanding words, sentences and context will not correctly understand verbal information and may experience aggravated conditions of education in the school, although their problems may not be visible "at a glance."

co-occurring condition. With SLI, the main symptoms of language nature include difficulty in producing speech and understanding words, sentences or context. According to Lorusso et al. [8], linguistic impairments in children with SLI disrupt abstract language processing more than

Comparison of the Results of Token Test and Sentence Comprehension Test in Pre‐school...

http://dx.doi.org/10.5772/intechopen.69709

153

Speech sound disorders include problems with articulation—**articulation disorder** (making sounds) and **phonological disorders** (sound patterns).The ability of humans to produce sounds is used to convey a message, and the act of producing such sounds is identified as **articula‐ tion**, and this activity is a major component of speech as distinguished from the term language [9, p. 6]. **Phonological disorders** form a group of language disorders that affect the ability of the child (usually around 3 to 4 years of age) to mimic the speech patterns of words in adults; they affect the ability to learn and organize sounds into words. It is reported that the children show auditory discrimination problems and acoustic feedback weakening; these problems occur at the linguistic level, and they are not related to the creation of sounds by vocal organs [2].

The author of the contribution collected the research data during June 2016. In children of the

• Compare the success of children in understanding oral speech in terms of the type of

Regarding the research methods of data collection, the oral speech understanding component was examined using the Token Test (TT) [10] and the Sentence Comprehension Subtest from the Heidelberg Language Development Test [11]. In all participating participants, with the consent of children's legal representatives, the examinations using the Token Test and Sentence Comprehension Subtest were recorded on a video camera. The video was taken with the intent to evaluate the children's reactions as precisely as possible. In all 27 children from the research sample, their oral speech understanding was examined by the author of this article. At the conclusion of the entire examination, the examiner briefly assessed the

Token Test (TT) assesses understanding of orally communicated sentences. It is a widely used diagnostic method utilized in the field of children's language, in neuropsychology and

visual-motor impairments in nonverbal learning disabilities.

selected research sample, the research goals were set as follows:

• Investigate understanding of oral speech by two methods.

• Evaluate the results of understanding oral speech.

children's work: "You see, well you made it."

**3. Research objectives**

kindergarten.

**4.1. Token Test**

**4. Research methods**

### **2. Basic terminology**

The concept of **comprehension** [2, 3] can be seen as a comprehension of relationship, respect, sense, and the substance of the problem; as a method of cognition, understanding is similar to intuition, and it is achieved directly. In speech therapy, the issue of understanding is closely related to the areas of language disorders. Language disorders pose difficulties in language encoding or decoding; they include difficulties in verbal communication, understanding, reading, writing, and problem-solving; in terms of processing language symbols, language disorders are divided into receptive and expressive. In case of a receptive language disorders (RLD), the understanding of words or sentences is disrupted. RLD affectees have difficulty in understanding the meaning of words and phrases when exposed to them, for example, they are asked to point at a named object or image, handling according to instructions is complicated, and demandingness increases with the length of sentences, variety of tasks, the use of a negation, etc. An important prerequisite for understanding the language is physiological and distinct speech (e.g., pronunciation, fluency, prosody) of the examiner. Expressive language disorder (ELD) causes difficulty with verbal expression, i.e., difficulty in formulating thoughts, difficulty in finding words, naming objects, in the lack of appropriate vocabulary, difficulty with semantics (linguistic branch of science, the science of meaning of words, phrases, and communications), difficulty with phonology (refers to speech sound, sound patterns, and rules of sound organization), difficulty with morphology (rules describing the form taken by individual words), and deficiencies in syntax (rules for building words in sentences) [2]. According to Prucha [4], the qualitative aspect of the process of learning the meanings of words, i.e., learning words as semantic categories, is illustrated much less than the quantitative aspect of learning vocabulary by children. According to Lerner and Johns [5], children with difficulties in understanding the language can understand separate simple words, such as "*to sit,*" "*chair,*" "*to eat,*" and "*biscuit,*" but they will have difficulty in understanding the sentence in which these words are used, such as: "*Sit in the chair only after eating the biscuit.*"

Developmental language disorders include **specific language impairment** (SLI). SLI is manifested by impaired ability or inability to learn to communicate verbally even if the conditions for the development of language (speech) are adequate [2]. According to Mikulajová [6], it is a neurobiological developmental disorder of speech; the children have impaired ability to understand speech and/or express themselves in speech compared to their peers. According to Shipley and McAfee [7], a seemingly pure language impairment with no obvious cause or co-occurring condition. With SLI, the main symptoms of language nature include difficulty in producing speech and understanding words, sentences or context. According to Lorusso et al. [8], linguistic impairments in children with SLI disrupt abstract language processing more than visual-motor impairments in nonverbal learning disabilities.

Speech sound disorders include problems with articulation—**articulation disorder** (making sounds) and **phonological disorders** (sound patterns).The ability of humans to produce sounds is used to convey a message, and the act of producing such sounds is identified as **articula‐ tion**, and this activity is a major component of speech as distinguished from the term language [9, p. 6]. **Phonological disorders** form a group of language disorders that affect the ability of the child (usually around 3 to 4 years of age) to mimic the speech patterns of words in adults; they affect the ability to learn and organize sounds into words. It is reported that the children show auditory discrimination problems and acoustic feedback weakening; these problems occur at the linguistic level, and they are not related to the creation of sounds by vocal organs [2].

### **3. Research objectives**

*"A cat is chased by a dog."* We decided to observe the issue of understanding oral speech in pre-school children because it far exceeds school education and offers new areas for research exploration. School work is imbued with permanently working with a given language in the area of reception (understanding) and expression (production)—in the speaking, reading and written forms. In some cases, pre-school children who face difficulties in understanding words, sentences and context will not correctly understand verbal information and may experience aggravated conditions of education in the school, although their problems may

The concept of **comprehension** [2, 3] can be seen as a comprehension of relationship, respect, sense, and the substance of the problem; as a method of cognition, understanding is similar to intuition, and it is achieved directly. In speech therapy, the issue of understanding is closely related to the areas of language disorders. Language disorders pose difficulties in language encoding or decoding; they include difficulties in verbal communication, understanding, reading, writing, and problem-solving; in terms of processing language symbols, language disorders are divided into receptive and expressive. In case of a receptive language disorders (RLD), the understanding of words or sentences is disrupted. RLD affectees have difficulty in understanding the meaning of words and phrases when exposed to them, for example, they are asked to point at a named object or image, handling according to instructions is complicated, and demandingness increases with the length of sentences, variety of tasks, the use of a negation, etc. An important prerequisite for understanding the language is physiological and distinct speech (e.g., pronunciation, fluency, prosody) of the examiner. Expressive language disorder (ELD) causes difficulty with verbal expression, i.e., difficulty in formulating thoughts, difficulty in finding words, naming objects, in the lack of appropriate vocabulary, difficulty with semantics (linguistic branch of science, the science of meaning of words, phrases, and communications), difficulty with phonology (refers to speech sound, sound patterns, and rules of sound organization), difficulty with morphology (rules describing the form taken by individual words), and deficiencies in syntax (rules for building words in sentences) [2]. According to Prucha [4], the qualitative aspect of the process of learning the meanings of words, i.e., learning words as semantic categories, is illustrated much less than the quantitative aspect of learning vocabulary by children. According to Lerner and Johns [5], children with difficulties in understanding the language can understand separate simple words, such as "*to sit,*" "*chair,*" "*to eat,*" and "*biscuit,*" but they will have difficulty in understanding the sentence in which these words are used, such as: "*Sit in the chair only after eating the biscuit.*"

Developmental language disorders include **specific language impairment** (SLI). SLI is manifested by impaired ability or inability to learn to communicate verbally even if the conditions for the development of language (speech) are adequate [2]. According to Mikulajová [6], it is a neurobiological developmental disorder of speech; the children have impaired ability to understand speech and/or express themselves in speech compared to their peers. According to Shipley and McAfee [7], a seemingly pure language impairment with no obvious cause or

not be visible "at a glance."

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**2. Basic terminology**

The author of the contribution collected the research data during June 2016. In children of the selected research sample, the research goals were set as follows:

### **4. Research methods**

Regarding the research methods of data collection, the oral speech understanding component was examined using the Token Test (TT) [10] and the Sentence Comprehension Subtest from the Heidelberg Language Development Test [11]. In all participating participants, with the consent of children's legal representatives, the examinations using the Token Test and Sentence Comprehension Subtest were recorded on a video camera. The video was taken with the intent to evaluate the children's reactions as precisely as possible. In all 27 children from the research sample, their oral speech understanding was examined by the author of this article. At the conclusion of the entire examination, the examiner briefly assessed the children's work: "You see, well you made it."

### **4.1. Token Test**

Token Test (TT) assesses understanding of orally communicated sentences. It is a widely used diagnostic method utilized in the field of children's language, in neuropsychology and cognitive investigations in general [1]. According to Ref. [10], all versions of the Token Test are based on the original work by Ennio De Renzi and Luigi Amadeus Vignola (1962 in Bolceková et al. [10]). For children, there is a Token Test for Children-Second Edition TTFC-2 (McGhee et al., 2007 in Paul and Norbury [12]). In our research, we used a shortened version of TT with 36 items divided into six parts. For examinations, we needed 20 tokens, varying in size (large and small), shape (round and square), and color (blue, green, yellow, white, and red). The proband's task was to handle the tokens according to instructions of the examiner. Demands on verbal working memory gradually increase in the first five parts, e.g., "*Touch the circle. Touch the blue shape. Touch the white square. Touch the large yellow circle. Touch the white square and the green circle. Touch the big white square and the small green circle.*" In the sixth part, the instructions are more complex and their proper fulfillment requires proper understanding of grammatical structures, e.g., "*Touch the blue circle with the red square. When it is a black circle, touch the red square. After touching the yellow circle, touch the blue circle.*" The demandingness of the instructions increases with the number of tokens involved in one handling and the number of characteristics (color, shape, and size), which must be considered for proper execution of the instruction. Correct and incorrect responses/reactions were evaluated by one or zero points, respectively. Each child could receive a maximum of 36 points. When assessing the level of understanding of oral speech, we used the following criteria: 29–36 points = no disorder, 25–28 points = minor disorder, 17–24 points = moderate disorder, 9–16 points = severe disorder, and 0–8 points = very severe disorder [10].

**5. Research sample**

glance."

and 9 months.

**Figure 1.** Composition of the sample by gender.

boys and six girls in the kindergarten of common type.

The research sample consisted of 27 children ranging in age from 4 years and 6 months to 7 years and 9 months. These children were from the pre-school section of two kindergartens in the Czech Republic. Ten children (37% of the monitored sample) attended a kindergarten of common type—this group included children (labeled P1-P10) with typical language development. Seventeen children (P11-P27), which means 63% of the monitored sample, attended a speech and language kindergarten due to communication difficulties. As shown in **Figure 1**, we worked with 14 boys and 3 girls in the speech and language kindergarten and with four

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We selected our specific participants in order to point out at difficulties in oral speech comprehension in children with speech-language disorders, especially with developmental language disorders. Their difficulties in sentence comprehension are not visible "at a

Regarding the 17 children from the speech and language kindergarten, school attendance in eight of them (47%) was postponed by 1 year. The situation was different in children from the kindergarten of common type; none of the 10 examined children had deferred school attendance. The youngest child was participant P6 from the kindergarten of common type, aged 4 years and 6 months. The oldest child from the kindergarten of common type (P3) was aged 6 years and 9 months.  The youngest participant (P25) from the speech and language kindergarten was aged 5 years

We were interested in the sample composition **for reason of inclusion in the speech and language kindergarten** (**Figure 2**). Children-participants were labeled P11 up to P27. One of them (P14) was diagnosed with delayed speech development and minor articulation disorder. Four children (P15, P16, P17 and P22) had severe articulation disorder, which

### **4.2. Sentence Comprehension Test**

Twenty-seven children received a subtest from the Heidelberg Language Development Test H-S-E-T (Heidelberg speech evolution test, henceforth H-S-E-T) [11] called the Sentence Comprehension Test (SCT). The Heidelberg Language Development Test was originally created to the German language and was adapted from German to Slovak language by Mikulajová [11], translated to the Czech language by Smékalová [11]. The test is not standardized for the Czech language, and the orientation standards taken from Slovakia are applied. We do not have many options in the Czech Republic to diagnose language development in childhood, and the area of understanding the syntactic structures can be diagnosed by the Sentence Comprehension Subtest by a speech-language pathologist. H-S-E-T is intended for children from 4 to 9 years of age; it has 13 subtests and assesses the level of language skills. Individual subtests of the H-S-E-T, for example, focus on sentence comprehension, the ability to form plurals and singulars, on repeating phrases, the ability to form derived words, ability to form sentences, and other language areas. Subtest Sentence Comprehension Test (SCT) contains 10 instructions of varying grammar complexity; the task of a child is to handle objects according to instructions spoken by the examiner. Examples of instructions (for 5-year-old and older children) are the following sentences: "*The duck swam before the sheep lay down. The rabbit let the cat stroke the dog.  Grimmová et al. [11] indicate that the child will resolve these tasks incorrectly when insisting only on surface strategies without penetrating into the semantic depth of sentences. Children's reactions are evaluated as either correct or incorrect. Correct and incorrect responses are evaluated by one or zero points, respectively. In the subtest, children could receive a maximum of 10 points.

### **5. Research sample**

cognitive investigations in general [1]. According to Ref. [10], all versions of the Token Test are based on the original work by Ennio De Renzi and Luigi Amadeus Vignola (1962 in Bolceková et al. [10]). For children, there is a Token Test for Children-Second Edition TTFC-2 (McGhee et al., 2007 in Paul and Norbury [12]). In our research, we used a shortened version of TT with 36 items divided into six parts. For examinations, we needed 20 tokens, varying in size (large and small), shape (round and square), and color (blue, green, yellow, white, and red). The proband's task was to handle the tokens according to instructions of the examiner. Demands on verbal working memory gradually increase in the first five parts, e.g., "*Touch the circle. Touch the blue shape. Touch the white square. Touch the large yellow circle. Touch the white square and the green circle. Touch the big white square and the small green circle.*" In the sixth part, the instructions are more complex and their proper fulfillment requires proper understanding of grammatical structures, e.g., "*Touch the blue circle with the red square. When it is a black circle, touch the red square. After touching the yellow circle, touch the blue circle.*" The demandingness of the instructions increases with the number of tokens involved in one handling and the number of characteristics (color, shape, and size), which must be considered for proper execution of the instruction. Correct and incorrect responses/reactions were evaluated by one or zero points, respectively. Each child could receive a maximum of 36 points. When assessing the level of understanding of oral speech, we used the following criteria: 29–36 points = no disorder, 25–28 points = minor disorder, 17–24 points = moderate disorder, 9–16 points = severe

Twenty-seven children received a subtest from the Heidelberg Language Development Test H-S-E-T (Heidelberg speech evolution test, henceforth H-S-E-T) [11] called the Sentence Comprehension Test (SCT). The Heidelberg Language Development Test was originally created to the German language and was adapted from German to Slovak language by Mikulajová [11], translated to the Czech language by Smékalová [11]. The test is not standardized for the Czech language, and the orientation standards taken from Slovakia are applied. We do not have many options in the Czech Republic to diagnose language development in childhood, and the area of understanding the syntactic structures can be diagnosed by the Sentence Comprehension Subtest by a speech-language pathologist. H-S-E-T is intended for children from 4 to 9 years of age; it has 13 subtests and assesses the level of language skills. Individual subtests of the H-S-E-T, for example, focus on sentence comprehension, the ability to form plurals and singulars, on repeating phrases, the ability to form derived words, ability to form sentences, and other language areas. Subtest Sentence Comprehension Test (SCT) contains 10 instructions of varying grammar complexity; the task of a child is to handle objects according to instructions spoken by the examiner. Examples of instructions (for 5-year-old and older children) are the following sentences: "*The duck swam before the sheep lay down. The rabbit let the cat stroke the dog.  Grimmová et al. [11] indicate that the child will resolve these tasks incorrectly when insisting only on surface strategies without penetrating into the semantic depth of sentences. Children's reactions are evaluated as either correct or incorrect. Correct and incorrect responses are evaluated by one or zero points, respectively. In the subtest, children could

disorder, and 0–8 points = very severe disorder [10].

**4.2. Sentence Comprehension Test**

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receive a maximum of 10 points.

The research sample consisted of 27 children ranging in age from 4 years and 6 months to 7 years and 9 months. These children were from the pre-school section of two kindergartens in the Czech Republic. Ten children (37% of the monitored sample) attended a kindergarten of common type—this group included children (labeled P1-P10) with typical language development. Seventeen children (P11-P27), which means 63% of the monitored sample, attended a speech and language kindergarten due to communication difficulties. As shown in **Figure 1**, we worked with 14 boys and 3 girls in the speech and language kindergarten and with four boys and six girls in the kindergarten of common type.

We selected our specific participants in order to point out at difficulties in oral speech comprehension in children with speech-language disorders, especially with developmental language disorders. Their difficulties in sentence comprehension are not visible "at a glance."

Regarding the 17 children from the speech and language kindergarten, school attendance in eight of them (47%) was postponed by 1 year. The situation was different in children from the kindergarten of common type; none of the 10 examined children had deferred school attendance. The youngest child was participant P6 from the kindergarten of common type, aged 4 years and 6 months. The oldest child from the kindergarten of common type (P3) was aged 6 years and 9 months.  The youngest participant (P25) from the speech and language kindergarten was aged 5 years and 9 months.

We were interested in the sample composition **for reason of inclusion in the speech and language kindergarten** (**Figure 2**). Children-participants were labeled P11 up to P27. One of them (P14) was diagnosed with delayed speech development and minor articulation disorder. Four children (P15, P16, P17 and P22) had severe articulation disorder, which

**Figure 1.** Composition of the sample by gender.

**Figure 2.** Composition of the sample for reason of inclusion in the speech and language kindergarten.

was accompanied by difficulties in graphomotorics, visual motor skills, oral motor skills, and auditory and visual perception in various combinations. Participant P18 struggled with incipient stuttering, impaired articulation, difficulty in graphomotorics, and visual perception. Eight children (P12, 13, 19, 20, 21, 24, 26, and 27) attended the speech and language kindergarten due to SLI, dysgrammatismus, difficulties in speech comprehension and production, difficulties in graphomotorics, oral motor skills, visual motor skills, and visual and auditory perception. One boy (P23) was diagnosed with severe bilateral sensorineural hearing loss compensated by hearing aids, difficulties in graphomotorics, and visual perception. Another boy (P25) struggled with symptomatic speech disorder in terms of dysarthria based on primary impaired mobility, spinal muscular atrophy with respiratory deficiency, and type II SMA. Examination of understanding of oral speech in this boy (P25) took place in the presence of an assistant teacher who cares for the boy in his kindergarten. Participant P11 came from a Russian-speaking environment and had slight difficulty in producing speech; his speech contained specific grammar errors and incorrect articulation.

### **6. Results**

The success results of the children in the Token Test are shown in **Figure 3**. These results are expressed by the number of points—the absolute rate of successful responses. The risk of moderately severe comprehension disorder (17–24 achieved points of a total of 36 points) was observed in seven participants (P13, P14, P15, P17, P19, P20 and P27) from the speech and language kindergarten (**Tables 1** and **2**). In participants P13, P19, P20 and P27, the deficits

were associated with SLI diagnosis. Participants P14, P15 and P17 attended the speech and language kindergarten due to impaired articulation and phonological disorder. The risk of very severe comprehension disorder (0–8 achieved points of a total of 36 points) was found in one boy (P23) with severe bilateral sensorineural hearing impairment compensated by

**Number of points Degree of understanding of oral speech**

**Table 1.** Degree of understanding of oral speech (according to DeRenzi and Faglioni, 1978 in Bolceková et al. [10]).

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**Participant Number of correct responses (n) Relative number (in %)**

P13 24 67 P14 20 56 P15 24 67 P17 18 50 P19 22 61 P20 21 58 P23 7 19 P27 24 67

**Table 2.** Results in Token Test at children with comprehension disorders.

29–36 No disorder 25–28 Minor disorder 17–24 Moderate disorder 9–16 Severe disorder 0–8 Very severe disorder

**Figure 3.** Success rate of Token Test.

**Figure 3.** Success rate of Token Test.

was accompanied by difficulties in graphomotorics, visual motor skills, oral motor skills, and auditory and visual perception in various combinations. Participant P18 struggled with incipient stuttering, impaired articulation, difficulty in graphomotorics, and visual perception. Eight children (P12, 13, 19, 20, 21, 24, 26, and 27) attended the speech and language kindergarten due to SLI, dysgrammatismus, difficulties in speech comprehension and production, difficulties in graphomotorics, oral motor skills, visual motor skills, and visual and auditory perception. One boy (P23) was diagnosed with severe bilateral sensorineural hearing loss compensated by hearing aids, difficulties in graphomotorics, and visual perception. Another boy (P25) struggled with symptomatic speech disorder in terms of dysarthria based on primary impaired mobility, spinal muscular atrophy with respiratory deficiency, and type II SMA. Examination of understanding of oral speech in this boy (P25) took place in the presence of an assistant teacher who cares for the boy in his kindergarten. Participant P11 came from a Russian-speaking environment and had slight difficulty in producing speech; his speech contained specific grammar errors and incorrect

**Figure 2.** Composition of the sample for reason of inclusion in the speech and language kindergarten.

The success results of the children in the Token Test are shown in **Figure 3**. These results are expressed by the number of points—the absolute rate of successful responses. The risk of moderately severe comprehension disorder (17–24 achieved points of a total of 36 points) was observed in seven participants (P13, P14, P15, P17, P19, P20 and P27) from the speech and language kindergarten (**Tables 1** and **2**). In participants P13, P19, P20 and P27, the deficits

articulation.

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**6. Results**

**Table 1.** Degree of understanding of oral speech (according to DeRenzi and Faglioni, 1978 in Bolceková et al. [10]).

**Table 2.** Results in Token Test at children with comprehension disorders.

were associated with SLI diagnosis. Participants P14, P15 and P17 attended the speech and language kindergarten due to impaired articulation and phonological disorder. The risk of very severe comprehension disorder (0–8 achieved points of a total of 36 points) was found in one boy (P23) with severe bilateral sensorineural hearing impairment compensated by hearing aids. The two youngest participants (P6, 4 years and 6 months, and P8, 5 years and 4 months) achieved 19 and 22 points; these results, however, were predicted because of their age. A positive development of language functions was indicated in both of these boys, and it could be assumed that their oral speech comprehension would continue to develop positively.

The most difficult instruction of the Token Test was the 29th where the least number of children was able to follow it (*N* = 6, 22%): *"If there is a black circle, touch the red square."* Only seven children (26%) successfully reacted to the 25th instruction: *"Touch the blue circle with a red square."* Ten out of 27 (37%) successfully performed the 30th, 34th, and the 36th instruction: *"Put the green square next to a red circle. Touch the red circle, not the white square. After touching the yellow circle, touch the blue circle.*"The instructions no. 5, 6, and 7: *"Touch a blue shape. Touch a green shape. Touch a white shape."* were all successfully completed by every child.

**Figure 4** and **Table 3** show that the most pronounced difficulties with sentence comprehension (H-S-E-T) occurred in participants P13, P14, P17, P20, P23, and P25. Participants P19, P21, and P27 gave only four correct responses out of 10. Instruction processing was very difficult in participants with SLI (P13, P19, P20, P21 and P27) and also in participants P14 and P17 who struggled with impaired articulation and phonological disorder. We observed serious problems in the area of comprehension in P23, the boy with severe bilateral sensorineural hearing impairment compensated by hearing aids, and P25, the boy with dysarthria pursuant to spinal muscular atrophy with respiratory deficiency, type II SMA. Considerable difficulties were associated with the implementation of instructions containing time sequences expressed by prepositions *"before"* and *"after."* Children were the most successful in following the third instruction, which, as the only one, was expressed in a simple sentence of four words. Twenty-four children (89%) correctly followed the third instruction. The other nine sentences contained six or seven words, which demanded, apart from adequate language processing of the sentence, a high level of working verbal-acoustic memory.

**7. Conclusions**

In the monitored groups, we noted differences in the results of the Token Test and Sentence Comprehension Test, in favor of children from the kindergarten of common type. **Figure 5** shows that children with typical speech development from the kindergarten of common type

achieved an average success of 77% in the Token Test and 59% in the Sentence.

**Figure 5.** Comparison of success rates of Token Test and Sentence Comprehension Test.

**Table 3.** Results in Sentence Comprehension Test at children with comprehension disorders.

**Participant Number of correct responses (n) Relative number (in %)**

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P1 4 40 P13 3 30 P14 0 0 P17 2 20 P19 4 40 P20 3 30 P21 4 40 P23 0 0 P25 2 20 P27 4 40

**Figure 4.** Success rate of Sentence Comprehension Test (H-S-E-T).

**Table 3.** Results in Sentence Comprehension Test at children with comprehension disorders.

### **7. Conclusions**

hearing aids. The two youngest participants (P6, 4 years and 6 months, and P8, 5 years and 4 months) achieved 19 and 22 points; these results, however, were predicted because of their age. A positive development of language functions was indicated in both of these boys, and it could be assumed that their oral speech comprehension would continue to develop

The most difficult instruction of the Token Test was the 29th where the least number of children was able to follow it (*N* = 6, 22%): *"If there is a black circle, touch the red square."* Only seven children (26%) successfully reacted to the 25th instruction: *"Touch the blue circle with a red square."* Ten out of 27 (37%) successfully performed the 30th, 34th, and the 36th instruction: *"Put the green square next to a red circle. Touch the red circle, not the white square. After touching the yellow circle, touch the blue circle.*"The instructions no. 5, 6, and 7: *"Touch a blue shape. Touch a green shape.*

**Figure 4** and **Table 3** show that the most pronounced difficulties with sentence comprehension (H-S-E-T) occurred in participants P13, P14, P17, P20, P23, and P25. Participants P19, P21, and P27 gave only four correct responses out of 10. Instruction processing was very difficult in participants with SLI (P13, P19, P20, P21 and P27) and also in participants P14 and P17 who struggled with impaired articulation and phonological disorder. We observed serious problems in the area of comprehension in P23, the boy with severe bilateral sensorineural hearing impairment compensated by hearing aids, and P25, the boy with dysarthria pursuant to spinal muscular atrophy with respiratory deficiency, type II SMA. Considerable difficulties were associated with the implementation of instructions containing time sequences expressed by prepositions *"before"* and *"after."* Children were the most successful in following the third instruction, which, as the only one, was expressed in a simple sentence of four words. Twenty-four children (89%) correctly followed the third instruction. The other nine sentences contained six or seven words, which demanded, apart from adequate language pro-

*Touch a white shape."* were all successfully completed by every child.

cessing of the sentence, a high level of working verbal-acoustic memory.

**Figure 4.** Success rate of Sentence Comprehension Test (H-S-E-T).

positively.

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In the monitored groups, we noted differences in the results of the Token Test and Sentence Comprehension Test, in favor of children from the kindergarten of common type. **Figure 5** shows that children with typical speech development from the kindergarten of common type achieved an average success of 77% in the Token Test and 59% in the Sentence.

**Figure 5.** Comparison of success rates of Token Test and Sentence Comprehension Test.

Comprehension Test: children from the speech and language kindergarten achieved an average success of 70% in the Token Test and 44% in the Sentence Comprehension Test. **Figure 5** shows that children with TLD were more successful in the Token Test by 7% and by 15% in the Sentence Comprehension Test than children from SLK.

**Table 4.** Data about gender, age, diagnosis, and results in Token Test and Sentence Comprehension Test.

**Diagnosis Token Test Sentence Comprehension**

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**n/36 % n/10 %**

**Test**

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