LANGUAGE DISORDERS IN PATIENTS WITH AUTISM SPECTRUM DISORDER

REGISTRO DOI: 10.5281/zenodo.10465396

BRITO, Daiane Cavalcante dos Santos de¹
ANDRADE, Paulo Henrique²
GONÇALVES, Daniella Moura³
CARNEIRO, Neemias Santos⁴
CORDEIRO, Lucas Gerke⁵

Abstract: Language acquisition is a complex process that relies on biological, cognitive, psychological, and social aspects favorable to the construction of functional language. However, if there is structural or functional impairment during the language acquisition period, there will be damage to the child’s global and cognitive development. The purpose of the study is to describe and present the different characteristics of language disorders in patients with mild or moderate Autism spectrum disorder (ASD) and mild or moderate Intellectual disability (ID). It is a cross-sectional and analytical study, for language assessment, we utilized the Language Development Protocol (ADL 2), which analyzes Receptive Language (RL), Expressive Language (EL) and Global Language (GL). Convenience sampling consisted of 11 participants, users of the CERIV/APAE assisted in the speech therapy sector. Through this study, we evidenced the implications entailed by language disorders for the global functional development of patients with mild or moderate ASD when associated with mild or moderate ID.

Keywords: Developmental language disorder; Autistic Spectrum Disorder; Diseases of the Central Nervous System; Neuronal Plasticity; Communication.

1 Introduction

Many theories explain the language acquisition process, exposing relevant foundations for the construction of symbol systems or codes of a language. Language acquisition is a complex process that relies on biological, cognitive, psychological, and social aspects favorable to the construction of functional language. Language significantly contributed to socio-cultural construction, and it has as its main attribution to enable a person to develop reading and writing activities and develop their mental, cognitive, and refined sensorial skills.

However, if there is structural or functional impairment during the language acquisition period, there will be damage to the child’s global and cognitive development. Studies demonstrate a higher prevalence of language disorders when compared to motor delay, being genetic and environmental factors related to these disorders. The neurological limitations manifested in children with Autism Spectrum Disorder (ASD) result in significant language disorders and, consequently, will present impairments in verbal communication, social difficulties, and irregularities in the execution of the symbolic function. According to the complexity of language development presented, we observed the necessity to investigate if there is a worsening in the language of autistic patients when associated with other comorbidities, highlighting the intellectual deficiency that is the most common incident (recurrent) associated with ASD.

Hence, the justification of this work is to identify the language disorders in patients with ASD and ID, contributing to the improvement of behavioral and social manifestations of patients with autism with the multidisciplinary team.

2 Methods

2.1 Type of Study

It is a cross-sectional and qualitative study, carried out in the Specialized Rehabilitation Center of the Association of Parents and Friends of Exceptional Children (CERIV/APAE) in Campo Grande, Mato Grosso do Sul.

2.2 Population Definition

The type sampling of the study was by convenience, which 11 children were the total number of patients, with authorization and signature of the Informed Consent Form (ICF) by the legal guardian, divided into four groups, according to the clinical picture presented of ASD OR ID:

Mild Autism Spectrum Disorder Group (MiASD n = 4): From the children assisted in the speech therapy sector of the CERIV/APAE, we invited those that presented language disorders and behavioral stiffness, between four to six complete years of age, literate or not, both sexes, and that had previously carried out in the institution (psychology sector) the Childhood Autism Rating Scale (CARS) evaluation. The instrument has 15 subscales, being considered for the rating estimate score lower than 30 points (no autism), 30 to 35 (mild and moderate autism), and 36 to 60 (moderate or severe autism) (1). Borderline values will depend on a careful clinical evaluation that will determine the classification concerning the degree of autism according to the evidenced manifestations by the patient. Regarding that, the interpretation by a specialized professional in the mental health field implies inadequate scores, compromising the assertive diagnosis about the degree of autism.

Moderate Autism Spectrum Disorder Group (MoASD n = 4): We invited to participate in the study children who presented language disorders and behavioral stiffness, assisted in the language therapy sector of CERIV/APAE, between four to six complete years of age, literate or not, both sexes, and that had previously carried out in the institution (psychology sector) the Childhood Autism Rating Scale (CARS) evaluation. The instrument has 15 subscales, being considered for the rating estimate score lower than 30 points (no autism), 30 to 35 (mild and moderate autism), and 36 to 60 (moderate or severe autism) (1). However, the borderline results may not be precise. Nevertheless, a careful clinical evaluation will determine the classification of mild autism or more projected to moderate. Thus, the subjective character of the observation and interpretation applied in the attributed scores to each item, especially by people outside the mental health field, may change the score more or less in a way that nothing replaces the professional vision of a physician specialized in autism.

Mild Autism Spectrum Disorder plus Moderate Intellectual Deficiency Group (MiASD + MID n=1): Because of the complexity presented in language development in a child with ASD, we observed among patients assisted in the language therapy center of CERIV/APAE the necessity to investigate if there is a worsening in the language of the autistic patient when associated with Intellectual Deficiency that is the most common limitation associated with ASD. Thus, participated in this study children between four to six complete years of age, literate or not, both sexes, and that had previously been submitted in the institution (psychology sector) the application of the CARS and Son-R 2 1/2-7(SON-QI) scale. The SON-QI instrument evaluates the general Intellectual Quotient (IQ) and classifies the IQ as superior (score ≥130), high average (120 to 129), average (110 to 119), low average (80 to 89), borderline (70 to 79) and very inferior (score < 69) (2).

Moderate Intellectual Deficiency Group (MID n=2): children with ID do not manifest evident symptoms until the preschool period, the signs usually are early perceived in those with greater severity. The first manifestation observed by the parents in these children is a deficit in the development of linguistic skills, presenting a delay in the process of mother tongue acquisition. Generally, these kids demonstrate a delay in the performance of executive, cognitive, language, and, consequently, social skills. That way, we considered participating in this study children between four to six complete years of age, literate or not, both sexes, and that had previously carried out in the institution the evaluation of the Son-R 2 ¹/2-7(SON-QI) instrument, non-verbal that measures the intellectual degree of children with ID.

Thus, children with ASD and severe ID diagnosis, indigenous, quilombolas, or with associated comorbidities (microcephaly, hydrocephalus, oppositional defiant disorder, attention deficit hyperactivity disorder, cerebral palsy, Down syndrome, hearing impairment, among others), were not considered. We carried out the data collection in a single stage.

2.3 Procedures

For the language evaluation, we utilized the Evaluation of Language Development – ADL (Figure 1), composed of two scales: Receptive Language (RL) and Expressive Language (EL), which allows the evaluation of the Global Language (GL) of the child. It is a standardized and validated Brazilian instrument that investigates the acquisition and content development (semantics) and structure (morphology and syntax) of the language in children from one to six years and eleven months old.

For the language level classification, we adopted the score proposed by the test based on the points of the Standard Score (SS). Regarding the level of impairment in language development classification, we considered a range of normality inside the scores of GL between 115 to 85 (standard deviation lower or higher than 1), mild disorder between 84 to 77 (standard deviation between <1,03 e <1,53), moderate disorder 76 to 70 (standard deviation between < 1,6 e <2), and severe disorder equal or lower than 69 (standard deviation of 2) (3).

The application of ADL2 activities generates a raw score of Receptive and Expressive Language that is converted into a standard score with the chronological age of the child. The Global Language is obtained by the sum of standard scores from Receptive and Expressive Language (Attachment 1,2,3).

Figure 1: Illustration of the utilized section of the Evaluation of Language Development (ADL 2)
Source: Maria Lúcia N. Meneses (2003).
Note: We opted not to translate the content of the figure to maintain the integrity of the ADL2 instrument, originally in Portuguese.

We carried out the administration of ADL2 in approximately 40 minutes, in a private room and individually – in the CERIV/APAE institution in the speech therapy sector.

2.4 Data Analysis

We tabled the collected data by Microsoft Word 2016. program for descriptive analysis.

2.5 Ethical Aspects

We submitted this project for analysis to the Research Ethics Committee of the Federal University of Mato Grosso do Sul and approved under the opinion 5,583,687. We include participants only after the signature of their legal guardians of the Informed Consent Form (ICF.)

3 Results

Human language is a complex entanglement of chemical and neuro-synaptic interactions between the five great brain areas. The main basic areas of the neuro language are Broca and Wernicke being the Broca area responsible for speech-motor articulation, and it is formed through motor impulses in the frontal lobe that stimulate and codify neural impulses of the skeletal muscles of the pharynx and larynx (intrinsic and extrinsic). In addition to this, the Wernicke area, through the arcuate fasciculus, promotes the intermediation between the motor part and is responsible for the speech recognition skill, interpretation, and association of information, an area that still requires a lot to unravel in the search for gaps in human language (4).

Table 1: Results of the Evaluation of Global Language Development of patients with mild or moderate autism spectrum disorder and moderate intellectual deficiency associated or not with mild autism spectrum disorder in Campo Grande City, 2023.

GRUP	CARS	SON-R 2 ¹/2-7	RL	EL	GL	GL CLASS
MiASD1	30	–	87	89	87	Normality
MiASD2	33	–	0	0	0	Acute disorder
MiASD3	29.5	–	94	100	97	Normality
MiASD4	32	–	82	87	84	Mild disorder
MoASD1	35.5	–	73	0	50	Acute disorder
MoASD2	35	–	80	85	80	Mild disorder
MoASD3	34	–	82	73	82	Mild disorder
MoASD4	34.5	–	69	0	50	Acute disorder
MiASD + MID1	70	75	73	0	50	Acute disorder
MID2	–	73	80	85	80	Mild disorder
MID3	–	70	82	73	82	Mild disorder

Legend: CARS = classification score of the level of ASD by the classification scale of autism in childhood. SON-R 2 ½ -7 = instrument that evaluates the intellectual coefficient. RL = receptive language score by ADL 2. EL = expressive language score by ADL 2. GL = global language score by ADL 2. LG CLASS = global language classification by ADL 2. MiASD= Mild Autistic Spectrum Disorder. MoASD = Moderate Autistic Spectrum Disorder. MiASD + MID = Mild Autistic Spectrum Disorder plus Moderate Intellectual Deficiency. MID = Moderate Intellectual Deficiency. Source: Authors, through the data extracted from CARS, SON-R21/2-7 and ADL2.

As seen in Table 1, independently of the degree of autism, language disorders occurred, according to ADL 2, between the groups of participants MiASD and MoASD, with a predominance of mild and normal disorders in GL, similar to CARS and SON-R 2 scales.

Language disorders found in the patients of this study presented similarities, as seen in Table 1 the values are borderline for the CARS scale once they depend on the examiner evaluation with subjectivity on the degree of disorder, explaining that even in different groups, there is complexity in the development of linguistic skills inside the pre-existing functionality standards. One of the examples is the MiASD1 and MiASD3 participants, who presented a predominance of normality in Global (GL) Language, even with borderline diagnosis for autism in children.

4 Discussion

The ADL2 results regarding the Development of Receptive (RL), Expressive (EL), and GL were obtained through the points of the Standard Score (SS), in which we found differences between autistic participants with a mild or moderate degree, also with children with the diagnosis of intellectual deficiency associated or not with mild autism spectrum disorder.

Concerning the hemispherical predominance, a theory proposed regarding the prevalence of cerebral hemispheres would determine that specific areas would be language areas, however, other researchers in the neurobiology field believe that language has multiple synapses, among which cortical and subcortical, exceeding classical areas that would activate physical and cognitive activities. Such theory would totally exemplify the result with the patients of this study, who presented various factors of GL changes depending on their social and environmental exposure, neurologically representing cortical and subcortical answers that would really extrapolate classical areas already studied, obtaining a differentiated cognition in the diverse groups studied (5). Thus, it is possible to observe that language would basically have a semantic function when organizing information through sounds and signals to later be expressed orally (pragmatics), these functions are represented by driving response between speech and its neural formation.

During this study, it was possible to perceive a daily necessity in the reinforcement of cognitive language teaching, aiming at establishing a neural standard network that would represent oral and written codes for the establishment of effective communication, this happens because the brain needs several neural reactions to achieve speech and reading processing, among other cognitive skills through synaptic relations between neurons, generating learning, we verified this fact through the monitoring of the participants of this research. The cognitive development demands great synaptic reinforcement of those needed in the process and deletion of those inapt for language evolution, forming a network of accumulated data, corroborating based on the idea of brain stiffness in individuals with ASD diagnosis (6).

Hence, what makes speech skills different among human beings is the details of the inter-synaptic interconnection of neurons. Therefore, our study corroborates with the authors in that learning linguistic skills would occur in several new chemical and neurobiological connections in already existing neurons and not by the formulation of new cells (7). In addition, that reinforces human neuroplasticity, being the essential environment for the development of the central nervous system, in which the individual can activate not utilized areas because of acute lesions or insufficient stimulation to develop different functions in different age groups, such functions would obviously decrease according to the aging.

Between MiASD2 (acute disorder) and MiASD4 (mild disorder), there were different results regarding GL concerning a mild degree of subjectivity seen by the CARS scale. However, in the clinical practice of the socio-cultural environment, the constancy of teaching associated with individual interventionist practices favored the changes in the final outcome, the great question would be if there is a real interaction between the environment, type of disorder, and therapeutic method utilized for the functional communication of the patient, requiring additional studies to unravel that. Research demonstrated relevance regarding the importance of the formation of new synaptic connections so that there is liberation of neurotransmitters in higher quantity in the postsynaptic membrane, favoring fixation of understating of speech codes, corroborating the concept of semantics primacy rather than language syntax, to which establishes a great connection with the results presented in this study (7).

MoASD1 and MoASD4 patients demonstrated acute disorder in GL, however, there is also a certain variation in the score of the CARS scale, maintaining disparity between the borderline values and association with worse language disorders in the group with ASD, enabling it to target new discussions of works related to the upgrading of the above scale, aiming at better determining the groups for clinical agreement. The relationship between language neuroscience and functional linguistics enables greater facility in the comprehension of patients diagnosed with neuroanatomical and neurophysiological disorders, ratifying the importance of differential diagnosis carried out by properly qualified professionals in clinical evaluation, CARS application, or other complementary tools (8).

Nowadays, in the field of neuro-linguistic science, we highlight the relevance of the human cognition domain for the development of functional language and how the human being positioned himself in the (virtual, imaginary, fictional) world that boosts the social consciousness since childhood to be formed (9-10). Thus, literature once again elevates the importance of the early cognitive stimulus, aiming at minimizing significant disorders in the development of metalinguistic aspects, such as observed in MoASD2 and MoASD3 patients with mild disorder in GL.

According to Lameira et al. (11), the deficit of cognitive skills would be because of mirror neuron dysfunction, representing disorders between the interpretation of intentions and imitations of actions (relevant to human language learning). It is possible to comprehend, thus, that individuals with MiASD + MID1 present significant disorders for the accomplishment of functional activities of individuals and also occur deficits in the necessary imitation of other people for literacy and language, exemplifying the characteristics of patients with ASD associated with ID. The mirror neurons are interlinked cells to visual and motor systems that, during events and information, are activated, leading the individual to comprehend the meaning of the event, degenerating a process of imitation. This information will be analyzed and planned by the prefrontal cortex, which will decide the relevance or not of imitating such behavior.

Similarly, about the social character of language, even if there are nerve cells that stimulate the imitation of certain linguistic behaviors, the traditions, and social rules are the ones that will influence someone’s language and not the biological behavior. Bertoque (12) suggests that metalinguistic skills that are associated with mirror neuron dysfunction are subjugated in the prefrontal cortex, molded by experiences in which the semantic aspects are constructed regarding the cognitive process and the several communicative contexts.

In MID2 and MID3 patients, we observed delays in the development of adaptive skills from communicative and motor language, these characteristics of intellectual deficiency reverberate in social interaction and cognitive deficit, hampering the progress to functional communication. In those with mild GL disorder, it is possible to observe the neurocognitive mechanisms that help the formation of more adaptive learning experiences, assisting in aspects related to the development of cognitive skills (memory, attention, language, creativity, and planning) (13).

5 Conclusion

As seen, the main characteristics of individuals with ASD are difficulties in the development of metalinguistic skills due to brain stiffness, resulting in significant impairment to social interaction. The identification of prodromal signs and early intervention causes a low reduction of grievances of GL after the intervention, significantly contributing to the increase of communication functionality, verbal, or nonverbal, learning, and social interaction. In front of that, neurolanguage science contributed to the treatment by facilitating the comprehension of the relations between language, brain, and cognition. Therefore, the multidisciplinary work that favors the identification, diagnosis, and early treatment, minimizing the behavioral damage and language acquisition of people with ID and ASD, is important.

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ATTACHMENT

Attachment 1 – Table 2: Transformation of the Raw Scores in Standard Scored of the comprehensive and expressive language in specific age groups. Campo Grande, 2023.

Attachment 2 – Table 3: Transformation of the Raw Scores in Standard Scored of the comprehensive and expressive language in specific age groups. Campo Grande, 2023

Attachment 3 – Table 4: Global Language Standard Score in specific age groups. Campo Grande, 2023.

¹Federal University Of Mato Grosso Do Sul
²Association of Parents and Friends of the Exceptional
³Association of Parents and Friends of the Exceptional
⁴Federal University of Health Sciences of Porto Alegre
⁵Federal University Of Mato Grosso Do Sul