Comunicação Breve
Mariana de Almeida Neubauer1 Fernanda Dreux Miranda Fernandes1
Keywords
Autism disorder Language Communication Assessment Speech-language pathology and
audiology
Descritores
Transtorno autístico Linguagem Comunicação Avaliação Fonoaudiologia
Correspondence address: Fernanda Dreux Miranda Fernandes Rua Cipotânea, 51, Cidade Universitária, São Paulo (SP), Brasil, CEP: 05630-160. E-mail: [email protected] Received: 11/01/2013
Accepted: 11/18/2013
Study carried out at the School of Medicine of Universidade de São Paulo – USP – São Paulo (SP), Brazil. (1) School of Medicine, Universidade de São Paulo – USP – São Paulo (SP), Brazil.
Financial support: São Paulo Research Foundation (FAPESP). Conlict of interests: nothing to declare.
diagnosis in children of the autism spectrum: checklist use
Peril funcional da comunicação e diagnóstico
fonoaudiológico de crianças do espectro do autismo:
o uso de um checklist
ABSTRACT
Purpose: The use of a different protocol to assess the same aspects of the Functional Communication Proile (FCP) may contribute to a faster and less expensive determination of individual proiles of abilities and inabilities. The purpose of this study was to verify the applicability of a checklist to replace the aforementioned complete protocol as a way to facilitate clinical and therapeutic follow-up processes. Methods: The participants in this study were 50 children aged from 3 to 12 years, with diagnoses within the autism spectrum who were receiving specialized speech-language therapy for at least six months. The participants were ilmed while interacting with the speech-language pathologist, and the data were transcribed to the FCP protocol. After the recording and prior to the transcription, the speech-language pathologists were asked to answer the checklist of Communicative Functions. Results: All answers on the checklist and on the FCP were compared. The results indicated that there were statistical differences in nine of the 20 communicative functions, and in nine of the 50 children. These results suggest that the checklist is eficient to describe a group of children but not to characterize them individually. Therefore, it is possible to identify differences in the communicative proile but not to specify the frequency with which each function occurs. Conclusion: The checklist can be used as a tool in the therapeutic follow-up processes of children with autism spectrum disorders, but it does not replace the complete FCP protocol.
RESUMO
INTRODUCTION
The importance of language in disorders within the autism spectrum is unique, because, contrary to other extensive de-velopment alterations in which language disorders are either symptoms or consequences of other deicits, language altera-tions in the autism spectrum correspond to one out of the three fundamental criteria that determine this diagnosis.
For this reason, they have been investigated(1) and revised by
several authors for decades(2,3). These studies have evolved toward
the notion that the central point of language alterations within the autistic spectrum is related to language’s functional use, and have thus counted on contributions from pragmatic theories, which enable the articulation of language and aspects of interaction and cognition as an individual’s development unfolds; this scenario comprises exactly the triad of fundamental dominions that is used to diagnose autism spectrum disorders(4).
In regard to aspects of conceptualization and diagnosis, the concept of autism spectrum(5) includes the axes that compose
the diagnostic systems proposed by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders(6), and by the World Health Organization in
the International Classiication of Diseases(7). The diagnosis
criteria in question always entail behavior observation and identiication, since a biological marker has not yet been identiied for autism(8).
The concept of autism spectrum allows for the complex interrelation among several clinical situations and not only their juxtaposition(9). But a discussion still exists concerning
exactly which disorders must be included in the autism spec-trum, although there is little disagreement about the existence of a spectrum.
The implications of diagnosis criteria based mainly on clinical observation have been extensively discussed(10), as
well as differential diagnoses among the clinical scenarios that compose the autism spectrum(11).
The notion that the most significant contribution that speech-language pathology and audiology can offer, both to research studies on the etiology of autism and to diag-nostic processes, is the determination of a clearer language phenotype, has guided research concerning the best criteria to describe this population’s language, the best way to obtain them, alternatives to elicit better performances, and thorough data analysis.
The aim of this study was to verify the applicability of a checklist to replace the complete protocol as a facilitating element in clinical and therapeutic follow-up processes. The participants were 50 children between 3 and 12 years of age who were assisted at a specialized service center on a weekly basis. The procedures do not entail the modiication of any elements in the routine of semiannual reassessments of each patient under care; we only required the speech-language pathologists to ill out the checklist and to verify the occurrence frequency of each communicative function and their means of expression. With the results obtained, we sought to statistically compare the answers provided on the checklist to the performance of each child, revealed by means of the Functional Communication
Proile. The purpose was to verify a potential equivalency in the application of both instruments to investigate communication in children and teenagers within the autism spectrum.
METHODS
This study was approved by the institution’s Ethics Committee, under report number 228-11. The partici-pants were 50 children aged between 3 and 12 years who were being systematically assisted on a weekly basis for at least six months (at least three months with the same speech-language pathologist), with diagnoses included in the autism spectrum.
The inclusion criteria established for the study were: sig-nature of the Informed Consent by one of the legal guardians of each participant, diagnosis included in the autism spectrum, and age under 12 years.
The materials used to register the data were: digital cam-corders, media (short DVDs), Functional Communication Proile protocols (Appendix 1) and Communicative Functions checklist (Appendix 2).
Each individual was recorded between April and May of 2012, with the purpose of transcribing the footage data onto the Functional Communication Proile protocol. Before the data were transcribed, the therapists (speech-language patholo-gists) were asked to ill out the Communication Functionality checklist. After the instrument had been handed in to the re-searcher, the data obtained from the footage were transcribed. Following the transcription of footage data to the Functional Communication Proile, these were also given to the researcher, with the purpose of compiling the information in a table, so that we could compare the data using a statistical method.
RESULTS
The 50 Communicative Functionality checklists were illed out, and 50 footage pieces were transcribed onto Functional Communication protocols. All answers on the Communicative Functionality checklists were tabulated, as well as the data from the Functional Communication Proile protocols.
Initially, it was necessary to equate the manner of classifying the results presented in both tests. Thus, we used the concept of quartiles for the answers on the Functional Communication Proile, and it was established that, in case a certain function was not observed, it would be classiied as “never occurring”; if it happened between one and four times, it would be clas-siied as “rarely occurring”; if it happened between ive and 12 times, it would be classiied as “occurring many times”; and if it happened 13 or more times, it would be classiied as “frequently occurring”.
The results indicated that, when the occurrence of each function was compared, different results were found in nine out of the 20 communicative functions (Table 1), namely: information request, protest, commentary, self-regulatory function, performative function, targeted, game, narrative, and protest expression, and in nine of the 50 individuals (Table 2).
does not characterize them; in other words, it is possible to know that they have different pragmatic proiles, but it is not possible to identify the frequency of occurrence of the functions.
The results also suggest that the checklist can be utilized as an alternative form of assessment that complements the Functional Communication Proile.
CONCLUSION
The possibility of thoroughly investigating the ability to utilize functional communication in individuals of the autism spectrum, based on the use of simple instruments applicable to family mem-bers and speech-language pathologists, represents an important alternative to the speech-language assessment of this population. The checklist can be used as a complementary instrument in periodi-cal pragmatic language assessments of patients within the autism spectrum, because it stresses each individual’s speciic issues. The use of the Functional Communication Proile is indispensable to an all-encompassing knowledge of the functions used by the patient.
*MAN elaborated the initial study proposal, organized and applied the procedures, analyzed the results, and wrote this paper in collaboration with FDMF, who organized the project and collaborated with data analysis and the discussion of the results.
REFERENCES
1. Wetherby A, Prutting C. Proiles of communicative and cognitive-social abilities in autistic children. J Speech Hear Res. 1984;27:364-77. 2. Fernandes FDM, Molini-Avejonas DR, Sousa-Morato PF. Peril funcional
da comunicação nos distúrbios do espectro autístico. Rev CEFAC. 2006;8(1):20-6.
3. Fernandes FDM, Molini DR, Barrichelo VMO. Aspectos funcionais e correlatos sociocognitivos na terapia fonoaudiológica para autismo infantil – um estudo preliminar. Infanto Rev Neuropsiquiatr Infanc Adolesc. 1997;5(2):77-83.
4. Bernard-Opitz V, Ing S, Kong TY. Comparison of behavioural and natural play interventions for young children with autism. Autism. 2004;8(3):319-32. 5. Barbaro J, Dissanayake C. Developmental profiles of infants and toddlers
with autism spectrum disorders identified prospectively in a community-based setting. J Autism Dev Disord. 2012;42(9):1939-48.
6. American Psychiatric Association. Manual de diagnóstico e estatística de distúrbios mentais (DSM - IV). São Paulo: Manole; 1994.
7. Organização Mundial da Saúde. Classiicação Internacional de Doenças. 10a ed. Porto Alegre: Artes Médicas; 1983.
8. Bedford R, Elsabbagh M, Gliga T, Pickles A, Senju A, Charman T, et al. Precursors to social and communication difficulties in Infants at-risk for autism: gaze following and attentional engagement. J Autism Dev Disord. 2012;42(10):2208-18.
9. Klin A. Asperger syndrome: an update. Rev Bras Psiquiatr. 2003;25(2):103-9. 10. Filipek PA, Steinberg-Epstein R, Book TM. Intervention for Autism
Spectrum Disorders. Neuro RX. 2006;3:207-16.
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LA, et al. The Study to Explore Early Development (SEED): a multisite epidemiologic study of autism by the Centers for Autism and Developmental Disabilities Research and Epidemiology (CADDRE) network. J Autism Dev Disord. 2012;42(10):2121-40.
13. Fernandes FDM, Amato CAH, Balestro JI, Molini-Avejonas DR. Orientação a mães de crianças do espectro autístico a respeito da comunicação e linguagem. J Soc Bras Fonoaudiol. 2011;23(1):1-7.
Table 1. Significant differences in the occurrence of functions on the checklist and on the Functional Communication Profile, found through Kruskal-Wallis’ test, for all individuals
p-value PI 0.027 PR <0.000 C 0.004 AR <0.00 PE 0.002 NF 0.010 J 0.001 NA 0.022 EP 0.001
Table 2. Significant differences in the occurrence of functions on the checklist and on the Functional Communication Profile, found through Kruskal-Wallis’ test, for each individual
p-value
Individual 2 0.003
Individual 3 0.002
Individual 10 0.025
Individual 12 0.033
Individual 28 0.045
Individual 30 0.018
Individual 40 0.048
Individual 43 0.002
Individual 48 0.033
DISCUSSION
Since its irst description, autism, its diagnosis and the type of communication functions used by autistic children have been studied with the purpose of inding increasingly more complete information on the topic and on individuals within the spectrum. It has been widely registered in the literature(12)
that the search for eficient alternative diagnostic methods that consider information provided by the parents of children in the autistic spectrum has been increasing rapidly.
Although there are many studies that compare the Functional Communication Proile to diagnostic tests(13) and
identify the communication functions most used by autistic children, this is the irst study to present a comparative analy-sis between the Functional Communication Proile and the Communicative Functionality checklist.
Appendix 1. Functional Communication Profile
Perfil funcional da comunicação Ficha – síntese individual
Nome: Data: Sujeito número: Avaliador: Atos comunicativos
Total: Por minuto: %:
Meios e Funções Comunicativas
Função Meio n % Função Meio n % Função Meio n %
J VE PO VE N VE
N VO N VO N VO
% G % G % G
NF VE PA VE EX VE
N VO N VO N VO
% G % G % G
XP VE PS VE XP VE
N VO N VO N VO
% G % G % G
PR VE PI VE NA VE
N VO N VO N VO
% G % G % G
AR VE RO VE EP VE
N VO N VO N VO
% G % G % G
RE VE E VE JC VE
N VO N VO N VO
% G % G % G
PE VE C VE TOTAL VE
N VO N VO N VO
% G % G % G
FICHA DE IDENTIFICAÇÃO Nome:
Data de nascimento: Número
Diagnóstico psiquiátrico: Contato:
Endereço: Telefone:
Appendix 2. Functional Communication Profile – checklist
Perfil Funcional da Comunicação - Checklist
Nome: ____________________________________Idade: ______________ Data: ____/____/______ Entrevistado: ______________________________
Funções Comunicativas Ocorrências Meio
S MV R N G VE VO
PO A criança pede objetos? Ex: quando quer um brinquedo pede de alguma forma. PA A criança pede para que você faça coisas para ela? Ex: pede ajuda para desmontar um brinquedo.
PS Há um tipo de brincadeira habitual que seja realizada entre você e a criança que esta solicite? Ex:
ergue os braços para você fazer cócegas
PC Pede autorização para fazer algo? Ex: pede antes de pegar um brinquedo.
Funções Comunicativas Ocorrências Meio
S MV R N G VE VO
PR A criança impede que façam o que ela não quer? Ex: segura sua mão quando não quer que
penteie o cabelo.
RO Agradece ou cumprimenta? Ex: diz “oi”, “tchau”, “obrigada”.
E Faz coisas para chamar sua atenção? Ex: quando você está distraído, ela se exibe para que
você olhe.
C Mostra coisas ou fala sobre elas? Ex: mostra brinquedos que gosta enquanto anda na rua ou
comenta o que fez na escola.
AR Regula o comportamento por meio de gestos ou fala? Ex: diz “não pode” quando sabe que não
pode fazer algo.
N Nomeia objetos ou figuras? Ex: diante de uma figura fala o que tem nela.
PE A criança brinca, imita gestos (ou sons) de forma convencional? Ex: imita sons, imita ações de
fazer comidinha.
EX Expressa reações emocionais? Ex: olha uma coisa que gosta e mostra que gostou.
RE A criança reage a estímulos ambientais? Ex: a criança ri com cócegas. Assusta-se quando ouve
um barulho forte.
NF Faz ações que parecem não ter objetivo? Ex: balança as mãos e o corpo.
J Faz brincadeiras simples? Ex: faz o carrinho andar, empilha blocos.
XP Explora ou manipula objetos? Ex: morde ou lambe brinquedos.
NA Conta uma história ou fatos reais? Ex: conta uma história.
EP Mostra descontentamento em relação a algo? Ex: a criança chora quando não gostou que você fez. JC Realiza ações compartilhadas? Ex: brinca com outra pessoa, guarda os brinquedos junto com outro.
Caption: S = Sempre; MV = Na Maioria das Vezes; R = Raramente; N = Nunca; G = gestual; VE = verbal; VO = vocal.
