Upload
dinhcong
View
224
Download
4
Embed Size (px)
Citation preview
HOW TO ADVANCE COGNITIVE AND
LINGUISTIC DEVELOPMENT OF PERSONS
WITH COGNITIVE DEVELOPMENTAL
DISORDERS?
Dr. Krisztina Bohács PhD
GEM Cognitive Clinic
ELTE
INTRODUCTION
Intellectual disability (ID) -- still a major health, educational
and social problem in the 21st century
Individuals with ID need special ways of instruction and
contents structured and layered according to their thinking
patterns
Passive acceptant approach (adapting the environment to the
present level of functioning of the individual) ↔ Active
modifying approach (enriching the individual’s copying
behaviour for a better quality of life)
INTRODUCTION (RESEARCH)
A large number of research studies have been carried out in order to determine best ways of teaching academic subjects, reading and mathematics to children with cognitive impairments (Buckley & Bird, 2001; Buckley, 2002; Ghesquiére & Ruijssenaars, 2005; Browder & Spooner, 2011).
However, relatively little attention has been paid to the cognitive development of children with developmental disabilities /Down syndrome, other genetic syndromes, pervasive developmental disorder (PDD) or cerebral paresis (CP)/.
Even less research on the impact of cognitive acceleration programs on children with serious cognitive and learning problems is rather limited (esp on programs that target fluid intelligence) (Kozulin et al., 2010).
THEORETICAL BACKGROUND I
DESCRIPTION OF ID;
DEFINITIONS AND CLASSIFICATION OF IDS
Based on IQ Scores Diagnostic and Statistical Manual of Mental Disorders, DSM – 4 in
Hu:
Borderline Intellectual Functioning: IQ 71-84;
Mild Intellectual Disability IQ 50-55 to appr. 70;
Moderate Intellectual Disability: IQ 35-40 to 50-55;
Severe Intellectual Disability IQ 20-25 to 35-40;
Profound Intellectual Disability: IQ below 20 or 25
Older approach – still permeates decisions of placement in
the segregative special school approach
THEORETICAL BACKGROUND I
DESCRIPTION OF ID;
DEFINITIONS AND CLASSIFICATION OF IDS
New DSM – 5: American Psychological Association’s annual meeting, San Francisco, May 2013
Emphasizes the change for a more comprehensive assessment – consideration of adaptive functioning rather than IQ test scores alone.
„By removing IQ test scores from the diagnostic criteria, but still including them in the text description of intellectual disability, DSM-5 ensures that they are not overemphasized as the defining factor of a person’s overall ability, without adequately considering functioning levels.”
THEORETICAL BACKGROUND I
THEORETICAL GROUNDS AND GENERAL PROBLEMS IN
COGNITIVE ACCELERATION
Main approach to ID: sensorial/motoric programs: into the motoric modality they infuse the simple mental operations of pairing, matching, sorting and sequencing’ (sometimes claimed to be „thinking” programs) -- „functional learning”, „meaning derives from effortful movement”, „purposeful doing approach”.
Metacognitive, thinking skills programs: refined abstract labels, operations are completed not (only) by ‘doing’, but in an internalized way on the level of mental representations. Emphasize decontextualisation of abstract principles from the concrete experience and explicitely mediate transfer: the recontextualisation of the generalized strategies into new contexts. Higher self-regulation in terms of behaviour in general and while learning.
THINKING SKILLS PROGRAMS
THEORETICAL BACKGROUND I
OVERVIEW, COMPARISION AND CLASSIFICATION OF AVAILABLE
COGNITIVE ACCELERATION PROGRAMS
FIE-Basic: The reason for our choice:
In Hungary we did not find any structured cognitive program that would systematically target fluid intelligence of children with ID.
This strong and high level of abstraction usually does not characterise other interventional approaches to intellectual developmental disabilities. Develops representational thought.
Represents metacognitive approach to early education (self-regulation).
THEORETICAL BACKGROUND II
LEARNING EXPERIENCE&BRAIN PLASTICITY (DEFINITIONS,
OVERVIEW OF HISTORY) AIM: TO CONVERGE NEUROSCIENCES AND COGNITIVE EDUCATION; CRITICAL ELEMENTS
IN COGNITIVE EDUCATION TO PROMOTE NEURAL PLASTICITY
The concept is a very important fundament of any
therapeutic intervention and on the level of psychological functions it may be called ’Structural Cognitive Modifiability’ or SCM.
The terms brain plasticity, neuroplasticity or neural-re-mapping : the brain’s ability to re-organize itself in micro- and macro-levels, according to new experiences, learning or injury (LeDoux, 2003; Kleim & Jones, 2008; Doidge, 2007; Joja, 2013).).
Conclusions of brain science on therapy/cognitive acceleration (Intensity effect; novelty effect; spread effect; persistence effect etc.) --- similar to the criteria of MLE
THEORETICAL BACKGROUND III
STRUCTURAL COGNITIVE MODIFIABILITY (SCM)
In line with modern brain placticity research in the 21th century, the SCM model has viewed the human organism as open, adaptive and amenable for change since already the 1950’s (Feuerstein, 1979).
It involves the capacity of the individual to be modified by learning and the ability to use whatever modification has occurred for future adjustments -- due to environmental demands (Feuerstein, Feuerstein & Falik, 2010).
In SCM model intelligence is defined as a changeable state rather than an immutable trait. Following Piaget, in this model cognition plays a central role in human modifiability.
THEORETICAL BACKGROUND IV
SHORT OVERVIEW OF FEUERSTEIN’S THEORY AND
APPLIED SYSTEMS
Piaget, Vygotsky and Feuerstein – Views about the
modifiability of intelligence Piaget: construction driven by biological maturation; Vygotsky: material tools
and psychological tools; Feuerstein: humans – intentionaliy/reciprocity;
meaning and transfer
Criteria of Mediated Learning Experience
The Deficient or Emerging Cognitive Functions
The Cognitive Map – Dimensions of the Task
FEUERSTEIN’S MLE
The therapist/caregiver interposes himself between a set of stimuli and the learner and modify the stimuli for the developing child (Feuerstein, 1979; Tzuriel, 2011). Focusing the child on selected aspects of stimuli by
changing the intensity, frequency and order of the stimuli; by arousing the child’s vigilance and perceptual acuity; and by trying to develop in the child the cognitive functions required for temporal, spatial and cause-and-effect relationships.
MLE processes are gradually internalized by the child so as to become an integrated mechanism of change within the child.
Provision of adequate MLE facilitates the development of various cognitive functions, learning sets, mental operations, strategies and need systems.
THEORETICAL BACKGROUND V
PROBLEMS WITH ASSESSMENT OF CHILDREN WITH ID
Need of assessment systems -- penetrate deeper, much more into the ’latent intelligence’ of the low-performing individual which may be hindered by physiological and affective-emotive factors.
Physiological, social, emotional, cognitive aspects are all closely interwoven in the low-performing child, that under standardized circumstances (when interferences are avoided, different types of questioning or feedback are not allowed for the sake of reliability, when greater intentionality in the interaction is forbidden), objective „measurement” of cognitive
abilities is not possible (Resing, 2000; Haywood & Lids, 2007).
For a molar intervention plan we need to make explicit the child’s learning strategies.
THEORETICAL BACKGROUND V
DYNAMIC ASSESSMENT
A new testing paradigm has evolved since the 1970’s (DA). Its philosophy originates from the social constructivist theories of Vygotsky (ZPD).
Dynamic Assessment (DA) should make it possible to evaluate the person’s learning potential/propensity, not just his or her actual knowledge and skills.
An active teaching process of a child’s perception, learning, thinking
and problem solving takes place. The process is aimed at modifying an individual’s cognitive functioning and observing subsequent changes in learning and problem solving patterns within the testing situation (Tzuriel, 2001, Lifshitz et al., 2011).
Unlike other assessments, where examiners seek to document an individual’s existing repertoire of cognitive abilities and make no attempt to change, guide, or improve the individual’s performance, the main goal of DA is to assess changes in performance. The changes are taken as indications of learning potential, that is, future development that will be realised provided that a cognitive intervention is applied (Tzuriel, 2011).
Dynamic
Assessment
Curriculum-based DA Content-free DA, Evaluating
pure cognitive structures
Standardized,
quantitative
Non- standardized,
qualitative
W. Resing (2000),
C. Lidz (2007), V. Aalsvoort
(2002)
R. Feuerstein, LPAD (1963)
D. Tzuriel (2001)
R. Deutsch&Mohammed
(2010)
Computerised DA
J. Guthke &J. Beckman
H. Swanson, C. Wiedl,
D. Tzuriel (2001)
M. Jensen, Guthke,
Raider& Caruso (1991);
Fiszdon& J. Johannesen
(2010); Jensen (2007)
DA in Second
Language Acquisition
Poehner (2008)
Figure 4.2 Classification of Dynamic Assessment Systems (Resource: Bohács, 2010 p. 314).
THE EMPIRICAL RESEARCH
The cognitive-affective rehabilitation of 15 children born with ID and other comorbid phenomena (autistic behaviors, obsessive-compulsive disorder /OCD/, ADHD and pervasive developmental disorder /PDD/) with a socioconstructivist cognitive intervention program (Feuerstein’s MLE, Mediated-Self Talk and FIE-Basic). A thorough intervention in a clinical laboratory for 24 months.
THE APPLIED INTERVENTION PROGRAM
FIE-Basic
Mediated Self-Talk
within the framework of Mediated Learning Experience as
for way of interaction
The time of acceleration: 24 months in each cases
Type of intervention sessions: one-to-one, this way deficient cognitive functions of the individuals could be targeted with greater precision than in group settings
Intensity: large (7-15 sessions per week) (about 1400 hours per child)
INTERVENTION PROGRAM, THE INSTRUMENTS
1. Organisation of Dots – Basic
2. Orientation in Space – Basic
3. From Unit to Group
4. Identifying Emotions
5. From Empathy to Action
6. Compare and Discover the Absurd
7.Tri-Channel Attentional Learning
8. Know and Identify
9. Think and Learn to Prevent Violance
10. Learning to Ask Questions for Reading Comprehension
11. Compare and Discover the Absurd – Basic Level 2
PARTICIPANTS, AIMS AND RESEARCH
QUESTIONS
Participants of our qualitative study (N=15) are randomly chosen individuals from all parts of the country and from all socio-economic backgrounds.
They have mild (n=5) to moderate intellectual developmental disorder (n=10) with very different etiology (genetic syndromes, cerebral paresis, perinatal brain injury and/or metabolic diseases) +
severe comorbid atypical behavioural and motoric phenomena atypical cognitive-emotive behaviours (autistic behaviour /auditory or
tactile sensitivity/, obsessive-compulsive behaviours, severe ADHD and/or motoric dysfunctioning (dyspraxia, ataxia and hemiphlegia).
Language: 4 children (Cases 3, 9, 11 and 13) non-verbal; 4 arrived for intervention with very restricted language abilities – holographic one-word or two-word sentences or fragmented speech.
METHODS OF THE EMPIRICAL RESEARCH
I. Multiple embedded case studies „In the field of cognitive psychology when complex markings of
impaired and unimpaired cognitive functions are examined, case studies are the most tangible ways of hypothesis testing.” (Szokolszky, 2004, p. 498).
Our research is viewed as a series of experiment where the cases can be interpreted as the repetition of the same intervention program and this “replication logic” is supposed to reveal support for theoretically similar results; or contrasting results for predictable reasons (Yin, 2003).
However, two of the main drawbacks of case studies are their vast demand of time and resources” (Szokolszky, 2004, p 499).
II. Descriptive Statistics and Test Statistics ‘Flexibility of the qualitative studies is not a reason to avoid
systematic and consequent handling of data. Summarizing all the data in tables and the endeavour to quanitfy the results helps to maintain the validity of the research (Szokolszky, 2004, p 411)’.
AIMS AND RESEARCH QUESTIONS
Not to test the effectiveness of FIE-Basic per se BUT what kind of changes we can elicite in the cognitive-behavioural condition of our participants; how far we can take them with our intervention.
The main hypothetical questions:
Hypothetical Question 1
We have evidence from international research studies that MLE and FIE-Basic have a positive effect on children with regular intelligence or children in the socially disadvantaged population (Ben-Hur &
Feuerstein, 2011; Salas et al., 2010). Is this possible to elicit changes in the development of fluid intelligence of children with moderate and mild intellectual disability as well?
AIMS AND RESEARCH QUESTIONS
Hypothetical Question 2
Is it possible to elicite changes in the participants’ conceptual development, receptive/expressive language and communication? Based on Ben-Hur’s and Feuerstein’s study (Ben-Hur & Feuerstein, 2011, see Chapter 3.6) we expect that the program will positively influence not only regular children’s conceptual development but also those who have intellectual disability.
Hypothetical Question 3
Is this possible to enhance the logic, reasoning abilities of children having moderate and mild intellectual disability? Based on Beasley we hypothized that our intervention will bring about changes in reasoning abilities of children in our atypical group as well (Beasley, 1984).
AIMS AND RESEARCH QUESTIONS
Hypothetical Question 4 Is this possible to develop these children to
metacognitive awareness, self-regulation and internalized psychological control while learning? The study of Alas et al. note that one of the effects of FIE-Basic on socially disadvantaged children was that their self-regulation have improved and the experimental group became less distracted (Alas et al, 2010). Based on Alas and the several criteria of MLE we expect that there will be growth in children’s self-regulation while treating stimuli.
Hypothetical Question 5 Will the elicited changes generalize to other areas
that we cannot prognose? Based on one of Feuerstein’s criterion about SCM (the generalizability of a change) we prognose that the induced changes will affect other areas of the individual’s functioning (Feuerstein, Rand & Feuerstein, 2006).
BLENDED ASSESSMENT – STATIC
TESTS+DYNAMIC ASSESSMENT SYSTEMS
Static tests:
Raven Coloured Matrices (Raven, 1938)
Peabody Passive Vocabulary Test (Dunn & Dunn, 1997)
Gardner Active Vocabulary Test (Gardner, 1990)
TROG Test (test for the Reception of Grammar) (Bishop, 1983)
DIFER (Nagy, Józsa, Vidákovich & Fazekasné, 2004)
Goodenough-Harris Drawing Test (Goodenough, 1926)
DYNAMIC ASSESSMENT SYSTEMS
Cognitive Abilities Profile (CAP) (Deutsch&Mohammed,
2009)
(attention, memory, receptive/expressive language, cognitive
operations, metacognition and behaviours while learning.
Learning Propensity Assessment Device Basic
(LPAD-Basic) (Feuerstein et al., 1999)
RESULTS
Some Cases
Summative Results
CASE 1 PRE-TEST HUMAN FIGURE DRAWING, APRIL
2007. RAW SCORE: 1. DQ: CATEGORY A.
CASE 1 SPONTANEOUS HUMAN FIGURE DRAWING, AFTER A
SESSION IN THE PRESENCE OF HIS FATHER. SEPTEMBER
2007. DQ: 47.
The child has started to
make relationships between
episodic data and integrate
visual and visuo-motor
skills. The effects of the
’Organisation of Dots’ tool
are obvious in the drawing:
one square form and dots
everywhere, vertical and
horizontal lines comprise
the visual organisation of
the child.
CASE 1 POST-TEST: „MY FATHER AND HIS CASTLE AND HIS HORSE,
JUST PULLING A CART. MY FATHER IS A KING AND I TRY TO DEPICT HIS ROBE
ON HIS ARMS”. APRIL 2009. DQ: 84.
CASE 3 PRE-TEST HUMAN FIGURE DRAWING, NOVEMBER 2007.
CRONOLOGICAL AGE: 5;7 YEARS. RAW SCORE: 1.DQ: CATEGORY A.
CASE 3 SPONTANEOUS HUMAN FIGURE DRAWING. TITLE
GIVEN BY THE CHILD: „A PASTRY-COOK HOLDING A SUNSHINE
COOKIE”. FEBRUARY 2009. DQ 90.
CASE 4 PRE-TEST HUMAN FIGURE DRAWING, JUNE
2008. CRONOLOGICAL AGE: 12;7 YEARS DQ: 38.
CASE 4 POST-TEST HUMAN FIGURE DRAWING. THE TITLE
GIVEN BY THE CHILD: „ME IN A SQUARED SHIRT.” JUNE 2010.
DQ: 60.
CASE 14 PRE-TEST HUMAN FIGURE DRAWING, DECEMBER
2010. CRONOLOGICAL AGE: 4;8 YEARS. DQ: CATEGORY „A”.
CASE 14 SPONTANEOUS HUMAN FIGURE DRAWING, NOVEMBER 2011. THE TITLE
GIVEN BY THE CHILD ‘MOTHER’. CRONOLOGICAL AGE:5;7 YEARS. DQ 95
CASE 14 SPONTANEOUS HUMAN FIGURE DRAWING. THE TITLE GIVEN BY
THE CHILD:„MUM”. APRIL 2011. CRONOLOGICAL AGE: 5;0 YEARS. DQ 80
CASE 14 SPONTANEOUS HUMAN FIGURE DRAWING. THE TITLE
GIVEN BY THE CHILD: „MY FAMILY HOLDING EACH OTHER’S
HAND”. DECEMBER 2012. CRONOLOGICAL AGE: 6;1 YEARS.
DQ 98
The child has
started to depict
human relations –
which is a virtual,
abstract concept.
This indicates
serious cognitive-
emotive
development in
Pervasive
Developmental
Disorder.
TABLE 15. AVERAGE IMPROVEMENT IN RAVEN’S COLORED MATRICES, PPVT AND
GARDNER’S EXPRESSIVE VOCABULARY TEST IN 2 YS
Mean of
improvement
Standard
deviation
Min.
Max.
Theoretical
maximum
Average
percentage
points of
improvement
Raven 10,57 5,90 0 24 36 29,37%
PPVT 43,71 23,76 11 101 150 29,14%
PPVT
(mental age in
months)
46,43 =
3 years, 10 months 20,06 12 90 - -
Gardner T 32,29 15,55 5 69 79 40,87%
TABLE 16. RESULTS OF PAIRED-SAMPLES T-TEST AND WILCOXON SIGNED-
RANK TEST (N=14)
Table 16. Results of Paired-samples T-test and Wilcoxon signed-rank test (n=14)
95%
confidence
interval of the
difference
Nonparametric
test for two
related sample
Mean
Standard
deviation
Standard
error of
mean Lower Upper t df Wilcoxon’s Z
Raven 10,57 6,12 1,64 7,04 14,18 6,460*** 13 -3,185**
Peabody 43,71 24,66 6,59 29,48 57,95 6,634*** 13 -3,296***
Gardner 32,29 16,14 4,31 22,97 41,61 7,484*** 13 -3,297***
Differences in cases with moderate ID
Raven 9,22 7,31 2,44 3,60 14,84 3,784** 8 -2,533*
Peabody 49,22 27,72 9,24 27,91 70,53 5,327*** 8 -2,666**
Gardner 35,11 19,40 6,47 20,20 50,02 5,430*** 8 -2,666**
Differences in cases with mild ID
Raven 13,00 1,87 0,84 10,68 15,32 15,538*** 4 -2,032*
Peabody 33,80 15,74 7,04 14,26 53,34 4,802** 4 -2,023*
Gardner 27,20 6,61 2,96 18,99 35,41 9,201*** 4 -2,032*
*** - p<0,001; ** - p<0,01; * - p<0,05
Notes: SD: This is the corrected standard deviation (the sum of squares divided by n-1
instead of n).
SUM OF RESULTS ON COGNITIVE ABILITIES
PROFILE (REASONING/LOGIC; LANGUAGE/COMMUNICATION; BEHAVIOURS)
RESULTS
Q1 (fluid intelligence)
Raven Colored Matrices showed an increase in general
intelligence by 29,37%p within the two year long intervention
period. PPVT has indicated a 3 year 10 month growth in
mental years within the two year long intervention time.
Analysis by test-statistics has indicated that there were
significant changes in the cognitive development of the
participants between pre-test and post-test measures on
Raven’s Colored Matrices (mean 10,57, SD=6,12, t=6,460,
p<0,001;).
RESULTS
Q2 (language, communication)
Analysis by test-statistics has indicated that there were
significant changes in receptive language of the participants
between pre-test and post-test measures on Peabody Passive
Vocabulary Test (mean 43,71, SD=24,66, t=6,634, p<0,001)
and Gardner’s Expressive Vocabulary Test (t=7,484, p<0,001;
mean 32,29, SD=16,14).
Results of Cognitive Abilities Profile also indicated that the
participants development had been striking in the domain of
language and communication (improved by a mean of
55,36%p within the two years long intervention).
RESULTS
The titles of the individual human figure drawings of the
participants also indicate that their conceptual development
(presented in the titles of the drawings) have become very rich
verbally.
Individual TROG test results have strengthened that
understanding syntactic structures has also developed,
generally between 2;4 -- 5;2 years during the 24 months long
intervention phase.
Out of the 4 non-verbal children 3 became verbal
RESULTS
Q 3 (reasoning)
According to Cognitive Abilies Profile results the domain of reasoning improved by 57,40%p within the 2 years. This proved to be the highest difference between pre- and post test measures by CAP.
70% of them has presented a constant comparative behaviour, a need to
compare everything they experienced and figure out a criteria for commonalities.
The appearance of ’Why’ and ’What for’ questions also suggest that their episodic world-view has started to decrease and they started to find relationship between objects, events or situations. All the individual drawings show as well that children started to sythetise their experience.
RESULTS
Q4 (self-regulation, metacognitive awareness)
According to CAP, strategic thinking and metacognition have grown by 53,75%p in two years. We may interpret children’s advancement on Raven test
also that they have a better regulation of their learning processes. CAP: a 56,1%p growth in the domain of ’Behaviours while learning’.
We mention from individual cases we could lead 74% of children with
intellectual disability to cognitive and metacognitive awareness – they could clearly recognise and name the operations they have been doing with concrete or abstract data (’I am comparing these three objects according to height’; ’I am creating a sequence where the number of the objects are growing by two’) and they could recognise simple operations in other context.
RESULTS
Q5 (generalisation)
Our participants have started to draw human
figures, family members or objects in a
spontaneous way parallel the cognitive intervention.
The rhythm, the growing quality and ease with
which these drawings have been created imply that
this process can be interpreted as a sign of
modifiability. No other studies have noted this
generalized change.
Development of human figure drawings means a
sythetized cognitive, motor and verbal
development.
FIGURE 104. DIAGRAMS OF HUMAN FIGURE DRAWING DEVELOPMENT --
AVERAGE PROGRESS OF CHILDREN WITH MODERATE ID IN TWO YEARS (SUM)
0
20
40
60
80
100
120
Pre 1st year 2nd year
Average progress in two years - cases with moderate ID
Case 1
Case 2
Case 3
Case 4
Case 5
Case 8
Case 9
Case 12
Case 13
FIGURE 105. DIAGRAMS OF HUMAN FIGURE DRAWING DEVELOPMENT --
AVERAGE PROGRESS OF CHILDREN WITH MILD ID IN TWO YEARS (SUM)
0
20
40
60
80
100
120
140
Pre 1st year 2nd year
Average progress in two years - cases with mild ID
Case 6
Case 7
Case 10
Case 14
Case 15
CONCLUSIONS
Our research has strengthened that the „boundaries of human
intellect can be enlarged” (Csapó, 2013), even in case of the
clinical population where traditional approach views abilities
as constant and immutable or minimally plastic. The
enhancement of fluid intelligence of children with intellectual
disability is possible.
There is a much wider „hidden” or „latent” learning potential in
most children belonging to the clinical population than we
have had earlier hypothesized -- given a thorough, molar,
individually tailored and intensive program focusing on
precognitive, cognitive, and metacognitive elements of
learning.
NOVELTY
The novelty of our research is that in Hungary a metacognitive
thinking skills program has never been applied with students
with intellectual disabilities
A novel approach to monitoring the condition of our
participants with dynamic assessment besides normative tests
– which let us clearly see possible molar developments not
necessarily indicated by regular testing procedures
FURTHER RESEARCH
Further research is needed to clarify the effectiveness of the
program -- more participants and control group. These
directions, however require considerable amount of financial
investments and time.
Very expensive program and demanding in terms of human
resources
THANK YOU FOR YOUR ATTENTION!