Comprehension: An overlooked component in augmented language development

Language impairments in people with autoimmune neurological diseases: A scoping review

INTRODUCTION

Autoimmune neurological diseases (ANDs) are a specific type of autoimmune disease that affect cells within the central and peripheral nervous system. ANDs trigger various physical/neuropsychiatric symptoms. However, language impairments in people with ANDs are not well characterized. Here we aimed to determine the kinds of language impairment that most commonly emerge in 10 ANDs, the characteristics of the patients (demographic, neurological damage), and the assessment methods used.

METHODS

We followed the PRISMA Extension for Scoping Reviews (PRISMA-ScR). PubMed and Google Scholar were searched. We used a list of search terms containing 10 types of ANDs (e.g., multiple sclerosis, acute disseminated encephalomyelitis) in combination with the terms aphasia, dysphasia, fluency, language, listening, morphology, phonology, pragmatics, reading, semantics, speaking, syntax, writing. The reference lists and citations of the relevant papers were also investigated. The type of AND, patient characteristics, neurological damage and examination technique, language tests administered, and main findings were noted for each study meeting the inclusion criteria.

RESULTS

We found 171 studies meeting our inclusion criteria. These comprised group studies and case studies. Language impairments differed largely among types of ANDs. Neurological findings were mentioned in most of the papers, but specific language tests were rarely used.

CONCLUSIONS

Language symptoms in people with ANDs are commonly reported. These are often not full descriptions or only focus on specific time points in the course of the disease. Future research needs to assess specific language functions in people with ANDs and relate their language impairments to brain damage at different stages of disease evolution.

Challenges of brain-computer interface facilitated cognitive assessment for children with cerebral palsy

Brain-computer interfaces (BCIs) have been successfully used by adults, but little information is available on BCI use by children, especially children with severe multiple impairments who may need technology to facilitate communication. Here we discuss the challenges of using non-invasive BCI with children, especially children who do not have another established method of communication with unfamiliar partners. Strategies to manage these challenges require consideration of multiple factors related to accessibility, cognition, and participation. These factors include decisions regarding where (home, clinic, or lab) participation will take place, the number of sessions involved, and the degree of participation necessary for success. A strategic approach to addressing the unique challenges inherent in BCI use by children with disabilities will increase the potential for successful BCI calibration and adoption of BCI as a valuable access method for children with the most significant impairments in movement and communication.

Convergent validity of functional communication tools and spoken language comprehension assessment in children with cerebral palsy

BACKGROUND

The majority of children with cerebral palsy (CP) experience challenges in functional communication from a young age. A pivotal aspect of functional communication is language comprehension. A variety of classification systems and questionnaires are available to classify and describe functional communication skills in children with CP. A better understanding of the convergent validity of (subsections of) these tools, as well as their relationship with spoken language comprehension, will be valuable in both clinical practice and research.

AIMS

To investigate the convergent validity of (subsections of) functional communication tools and the relationship with spoken language comprehension in children with CP.

METHODS & PROCEDURES

Cross-sectional data on 138 children were subdivided into three developmental stages based on (Dutch) educational phases: ages 18 months-3;11y (n = 59), 4;0-5;11 years (n = 37) and 6;0-8;11 years (n = 42). The following functional communication tools were used to classify and describe functional communication: Communication Function Classification System (CFCS), subscales of the Caregivers Priorities and Child Health Index of Life with Disabilities-Dutch Version (CPCHILD-DV) and the Focus on Communication Under Six-34 (FOCUS-34) questionnaire. Spoken language comprehension was assessed with the Computer-Based instrument for Low motor Language Testing (C-BiLLT). Correlations between the functional communication tools, and with the C-BiLLT, were calculated using Pearson's and Spearman's correlation coefficients. It was hypothesized a priori that correlations of at least 0.60 suggest good convergent validity.

OUTCOMES & RESULTS

At all developmental stages, a significant ordered decreasing tendency of communication outcomes was found across CFCS levels; lower CFCS levels were associated with lower scores on the CPCHILD-DV and FOCUS-34, and with a lower level of spoken language comprehension (C-BiLLT). Correlation coefficients of the functional communication tools exceeded 0.60 at all developmental stages. Correlations between C-BiLLT raw scores and the functional communication tools varied between 0.351 and 0.591 at developmental stage 18 months-3;11 years, between 0.781 and 0.897 at developmental stage 4;0-5;11 years, and between 0.635 and 0.659 at developmental stage 6;0-8;11 years.

CONCLUSIONS & IMPLICATIONS

The functional communication tools assessed in this study showed convergent validity at all developmental stages. The CFCS, currently most widely used in paediatric rehabilitation, is adequate in the classification of functional communication. However, for more detailed clinical goal setting and evaluation of change in functional communication, the additional use of FOCUS-34 or CPCHILD-DV is recommended.

WHAT THIS PAPER ADDS

What is already known on the subject A range of functional communication tools are available that help describe and classify functional communication in children with CP. These include the CFCS, subsections of CPCHILD-DV and FOCUS-34. The CFCS classifies functional communication in daily life with familiar and unfamiliar partners. Specific subsections of the CPCHILD-DV and FOCUS-34 include items that pertain to communicative participation. The innovative C-BiLLT provides a standardized method to assess spoken language comprehension in children with CP and significant motor impairments. What this paper adds to existing knowledge In the present study, convergent validity was confirmed between CFCS and specific subsections of the CPCHILD-DV and FOCUS-34. Correlations between these functional communication tools and the C-BiLLT were moderate to strong. What are the potential or actual clinical implications of this work? For clinical and research purposes (for instance, accurate prescription of augmentative and alternative communication-AAC), healthcare and educational professionals together with parents need to know how functional communication tools converge and how functional communication levels relate to the comprehension of spoken language. The CFCS provides a valid classification of functional communication abilities in children with CP. However, to measure change in functional communication and to evaluate treatment outcomes, use of additional functional communication tools such as the CPCHILD-DV and FOCUS-34 is recommended. When discrepancies are found between communicative abilities and spoken language comprehension, it is strongly recommended that valid tools are used in a more detailed examination of the child's spoken language comprehension skills and functional communication.

Determinants of spoken language comprehension in children with cerebral palsy

PURPOSE

To identify determinants of spoken language comprehension (SLC) in children with cerebral palsy (CP).

MATERIALS AND METHODS

Cross-sectional data of 207 children with CP were included: 82 toddlers (18 months-3;11 years), 59 preschool children (4;0-5;11 years), and 66 schoolchildren (6;0-8;11 years), across all Gross Motor Function Classification System (GMFCS) levels. SLC was assessed using the Computer-Based instrument for Low motor Language Testing (C-BiLLT). Potential determinants were retrieved from medical files and through parental questionnaires. Per developmental stage, multivariable regression analyses were used to assess determinants of SLC.

RESULTS

Fifty-nine percent of the children showed below average SLC. Significant determinants for SLC differed per developmental stage. In toddlers: age, motor type, functional communication and speech function (R² = 0.637); in preschool children: functional communication, speech function and language activities (R² = 0.820), and in schoolchildren: functional communication, intellectual functioning and arm-hand functioning (R² = 0.807). For all developmental stages, functional mobility was not a significant determinant.

CONCLUSIONS

A large proportion of children with CP across all GMFCS levels have SLC impairments. Findings indicate that SLC is strongly determined by functional communication classified with CFCS. We recommend standardized assessment and monitoring of SLC in all children with CP. IMPLICATIONS FOR REHABILITATIONChildren across all GMFCS levels can experience difficulties in spoken language comprehension.At all developmental stages, functional communication (classified with CFCS) is an important determinant of spoken language comprehension.Standardized assessment and monitoring of spoken language comprehension, language production, speech, and communication of all children with CP, is strongly recommended.When children show below average performances, especially in spoken language comprehension, intervening with speech and language therapy and guidance for parents, is advised.

Judicious Arrangement of Symbols on a Simulated Augmentative and Alternative Communication Display Optimizes Visual Attention by Individuals With Down Syndrome

PURPOSE

Aided augmentative and alternative communication (AAC) displays are often designed as symmetrical row-column grids, with each square in the grid containing a symbol. To maximize vocabulary on displays, symbols are often placed close to one another, and background color cuing is used to signal/differentiate symbols across different grammatical categories. However, from a visual and developmental standpoint, these display features (close-set symbols and use of background color cues) may not be optimal. In particular, placing symbols quite close together may result in visual crowding, in which individual symbols cannot be distinguished due to the presence of many neighbors, or flankers. This research sought to examine the role of display arrangement and background color cuing on the efficiency of visual attention during search.

METHOD

Ten adolescents and adults with Down syndrome underwent a visual search task while a research-based eye tracking system recorded their patterns of visual attention. Participants searched for symbol targets on displays with varying levels of visual crowding and background color cuing.

RESULTS

Spatial arrangements that reduced visual crowding and that used the spatial organization to cue the grammatical category of symbols resulted in significantly fewer fixations to nonrelevant distracters during search and reduced the likelihood of fixations away from the target once it was located. Background color was helpful in reducing the latency to find the target.

DISCUSSION

Spatial cues may offer a powerful means to maximize the efficiency of search within AAC displays. Background color cuing may facilitate speed to locate targets in these older individuals. Implications for AAC design, as well as future avenues for maximizing (growing) vocabulary, are discussed.

Providing visual directives via a smart watch to a student with Autism Spectrum Disorder: an intervention note

Smart watches are discreet and wearable tools that may be repurposed to improve directive-following for individuals with autism spectrum disorder (ASD). Specifically, a mentor can transmit just-in-time (JIT) visual supports (e.g., video clips, photographs, text) that depict an upcoming directive to a learner's smart watch to prompt the learner as needed from a distance. Using a single-case multiple probe design across settings, this investigation evaluated the effectiveness of providing text-based prompts on an Apple Watch ¹ to a child with ASD within a school setting. A mentor transmitted 2-step written directives via text message to the participant's Apple Watch. The participant was instructed to attend to, read, and follow directives received on the watch. Results demonstrated that the intervention improved directive-following as well as increased the instructor's distance from the learner. It is proposed that JIT supports sent to a learner's smart watch may reduce the obtrusiveness of traditional prompting while also maintaining the naturalness of ongoing social or academic interactions. Clinical limitations and implications are discussed.

Longitudinal Development of Receptive Vocabulary in Children with Cerebral Palsy and Anarthria: Use of the MacArthur-Bates CDI

OBJECTIVE

To examine receptive language growth in children with cerebral palsy (CP) and anarthria using a parent-reported measure of vocabulary.

METHOD

Scores from 47 children (29 males) with CP and anarthria were obtained from the vocabulary checklists on the MacArthur-Bates Communication Development Inventories (MCDI) and analyzed to examine the distribution of receptive language growth. Linear trajectories of word composite scores were created using a linear-mixed model, incorporating between two and ten data points per child.

RESULTS

Three different growth trajectories emerged: approximately 23% grew by 100 or more words per year, 13% grew by 50-100 words per year, and 64% grew by 50 words per year or less. Age-four vocabulary was strongly correlated with rate of increase in vocabulary.

CONCLUSION

Receptive vocabulary scores from the MCDI are increasing at a reduced pace for most children with CP and anarthria. More sensitive measures of language assessment are necessary to gain a complete picture of their language ability levels.

Intervention focus moderates the association between initial receptive language and language outcomes for toddlers with developmental delay

This ex-post facto study reanalyzed data from Romski et al. to examine whether intervention focus moderated the relationship between pre-intervention standardized measures of receptive language and post-intervention standardized measures of receptive and expressive language age and observations of expressive target vocabulary size. In all, 62 toddlers with developmental delay were randomly assigned to augmented communication-input (AC-I), augmented communication-output (AC-O), or spoken communication (SC) interventions. AC-I provided augmented language input via spoken language and a speech-generating device (SGD); AC-O encouraged the production of augmented output via an SGD; and SC provided spoken input and encouraged spoken output without using an SGD. Intervention focus moderated the impact of initial receptive language on expressive language age and expressive target vocabulary size. Participants in AC-I, when compared to those in the other two interventions, had a significantly stronger relationship between initial receptive language and post-intervention expressive language age. For expressive target vocabulary size, participants in AC-O showed a strong relationship and those in AC-I a slightly weaker relationship between initial receptive language and expressive target vocabulary size; no significant relationship was found in the SC group. Results emphasize that different interventions may have distinct outcomes for children with higher or lower initial receptive language.

Visual-graphic symbol acquisition in school age children with developmental and language delays

Augmented language systems have become both an integral component of communication intervention programs for children with severe communicative impairments and spurred research on their language and communication development. This study examined intrinsic and extrinsic factors that may influence the language development process for children with developmental disabilities, by exploring the relationship between varying degrees of symbol arbitrariness and extant speech comprehension skills in the discrimination, learning, and use of symbols for communication. For the study, 13 school-aged participants (M = 8.24 [years; months]), with both developmental and language delays, were provided experience with iconic Blissymbols and an arbitrary symbol set of lexigrams via observational computerized experience sessions. There was a modest difference in their ability to learn arbitrary versus iconic symbols. There were no differences if the vocabulary item was unknown prior to the symbol learning experience. These findings suggest that iconicity of a symbol may not be a critical factor in learning a symbol-referent relationship if a target referent is not yet known in comprehension.

Brief Report: Just-in-Time Visual Supports to Children with Autism via the Apple Watch:® A Pilot Feasibility Study

Using augmented input might be an effective means for supplementing spoken language for children with autism who have difficulties following spoken directives. This study aimed to (a) explore whether JIT-delivered scene cues (photos, video clips) via the Apple Watch^® enable children with autism to carry out directives they were unable to implement with speech alone, and (b) test the feasibility of the Apple Watch^® (with a focus on display size). Results indicated that the hierarchical JIT supports enabled five children with autism to carry out the majority of directives. Hence, the relatively small display size of the Apple Watch does not seem to hinder children with autism to glean critical information from visual supports.

A Synthesis of Relevant Literature on the Development of Emotional Competence: Implications for Design of Augmentative and Alternative Communication Systems

PURPOSE

Emotional competence refers to the ability to identify, respond to, and manage one's own and others' emotions. Emotional competence is critical to many functional outcomes, including making and maintaining friends, academic success, and community integration. There appears to be a link between the development of language and the development of emotional competence in children who use speech. Little information is available about these issues in children who rely on augmentative and alternative communication (AAC). In this article, we consider how AAC systems can be designed to support communication about emotions and the development of emotional competence.

METHOD

Because limited research exists on communication about emotions in a context of aided AAC, theory and research from other fields (e.g., psychology, linguistics, child development) is reviewed to identify key features of emotional competence and their possible implications for AAC design and intervention.

RESULTS

The reviewed literature indicated that the research and clinical attention to emotional competence in children with disabilities is encouraging. However, the ideas have not been considered specifically in the context of aided AAC. On the basis of the reviewed literature, we offer practical suggestions for system design and AAC use for communication about emotions with children who have significant disabilities. Three key elements of discussing emotions (i.e., emotion name, reason, and solution) are suggested for inclusion in order to provide these children with opportunities for a full range of discussion about emotions.

CONCLUSIONS

We argue that supporting communication about emotions is as important for children who use AAC as it is for children who are learning speech. This article offers a means to integrate information from other fields for the purpose of enriching AAC supports.

Reliability of the Dutch-language version of the Communication Function Classification System and its association with language comprehension and method of communication

AIM

The aims of this study were to determine the intra- and interrater reliability of the Dutch-language version of the Communication Function Classification System (CFCS-NL) and to investigate the association between the CFCS level and (1) spoken language comprehension and (2) preferred method of communication in children with cerebral palsy (CP).

METHOD

Participants were 93 children with CP (50 males, 43 females; mean age 7y, SD 2y 6mo, range 2y 9mo-12y 10mo; unilateral spastic [n=22], bilateral spastic [n=51], dyskinetic [n=15], ataxic [n=3], not specified [n=2]; Gross Motor Function Classification System level I [n=16], II [n=14], III, [n=7], IV [n=24], V [n=31], unknown [n=1]), recruited from rehabilitation centres throughout the Netherlands. Because some centres only contributed to part of the study, different numbers of participants are presented for different aspects of the study. Parents and speech and language therapists (SLTs) classified the communication level using the CFCS. Kappa was used to determine the intra- and interrater reliability. Spearman's correlation coefficient was used to determine the association between CFCS level and spoken language comprehension, and Fisher's exact test was used to examine the association between the CFCS level and method of communication.

RESULTS

Interrater reliability of the CFCS-NL between parents and SLTs was fair (r=0.54), between SLTs good (r=0.78), and the intrarater (SLT) reliability very good (r=0.85). The association between the CFCS and spoken language comprehension was strong for SLTs (r=0.63) and moderate for parents (r=0.51). There was a statistically significant difference between the CFCS level and the preferred method of communication of the child (p<0.01). Also, CFCS level classification showed a statistically significant difference between parents and SLTs (p<0.01).

INTERPRETATION

These data suggest that the CFCS-NL is a valid and reliable clinical tool to classify everyday communication in children with CP. Preferably, professionals should classify the child's CFCS level in collaboration with the parents to acquire the most comprehensive information about the everyday communication of the child in various situations both with familiar and with unfamiliar partners.

AAC and Early Intervention for Children with Cerebral Palsy: Parent Perceptions and Child Risk Factors

The current study examined parent perceptions of communication, the focus of early intervention goals and strategies, and factors predicting the implementation of augmentative and alternative communication (AAC) for 26 two-year-old children with cerebral palsy. Parents completed a communication questionnaire and provided early intervention plans detailing child speech and language goals. Results indicated that receptive language had the strongest association with parent perceptions of communication. Children who were not talking received a greater number of intervention goals, had a greater variety of goals, and had more AAC goals than children who were emerging and established talkers. Finally, expressive language had the strongest influence on AAC decisions. Results are discussed in terms of the relationship between parent perceptions and language skills, communication as an emphasis in early intervention, AAC intervention decisions, and the importance of receptive language.

Spoken language comprehension of phrases, simple and compound-active sentences in non-speaking children with severe cerebral palsy

BACKGROUND

Children with severe cerebral palsy (CP) (i.e. 'non-speaking children with severely limited mobility') are restricted in many domains that are important to the acquisition of language.

AIMS

To investigate comprehension of spoken language on sentence type level in non-speaking children with severe CP.

METHODS & PROCEDURES

From an original sample of 87 non-speaking children with severe CP, 68 passed the pre-test (i.e. they matched at least five spoken words to the corresponding objects) of a specifically developed computer-based instrument for low motor language testing (C-BiLLT), admitting them to the actual C-BiLLT computer test. As a result, the present study included 68 children with severe CP (35 boys, 33 girls; mean age 6;11 years, SD 3;0 years; age range 1;9-11;11 years) who were investigated with the C-BiLLT for comprehension of different sentence types: phrases, simple active sentences (with one or two arguments) and compound sentences. The C-BiLLT provides norm data of typically developing (TD) children (1;6-6;6 years). Binomial logistic regression analyses were used to compare the percentage correct of each sentence type in children with severe CP with that in TD children (subdivided into age groups) and to compare percentage correct within the CP subtypes.

OUTCOMES & RESULTS

Sentence comprehension in non-speaking children with severe CP followed the developmental trajectory of TD children, but at a much slower rate; nevertheless, they were still developing up to at least age 12 years. Delays in sentence type comprehension increased with sentence complexity and showed a large variability between individual children and between subtypes of CP. Comprehension of simple and syntactically more complex sentences were significantly better in children with dyskinetic CP than in children with spastic CP. Of the children with dyskinetic CP, 10-13% showed comprehension of simple and compound sentences within the percentage correct of TD children, as opposed to none of the children with spastic CP.

CONCLUSION & IMPLICATIONS

In non-speaking children with severe CP sentence comprehension is delayed rather than deviant. Results indicate the importance of following comprehension skills across all age groups, even beyond age 12 years. Moreover, the subtype of CP should be considered when establishing an educational programme for sentence comprehension, and augmentative and alternative communication support. In addition, educational programmes for children with severe CP should take into account the linguistic hierarchy of sentence comprehension when focusing on the input and understanding of spoken language comprehension.

Impact of PECS tablet computer app on receptive identification of pictures given a verbal stimulus

OBJECTIVE

The purpose of this brief report was to determine the effect on receptive identification of photos of a tablet computer-based augmentative and alternative communication (AAC) system with voice output.

METHODS

A multiple baseline single-case experimental design across vocabulary words was implemented. One participant, a preschool-aged boy with autism and little intelligible verbal language, was included in the study.

RESULTS

Although a functional relation between the intervention and the dependent variable was not established, the intervention did appear to result in mild improvement for two of the three vocabulary words selected.

CONCLUSION

The authors recommend further investigations of the collateral impacts of AAC on skills other than expressive language.

Teaching graphic symbol combinations to children with limited speech during shared story reading

The aim of this study was to determine the effect of an intervention strategy on the production of graphic symbol combinations in children with limited speech. Four children between the ages of 6;5 and 10;8 (years;months) with limited speech participated in the study. A single-subject, multiple probe design across three different types of semantic relations was used. Generalization to untrained exemplars was also monitored. Results were mixed across the four participants: two participants learned to combine symbols across different types of relations, maintained these skills post intervention, and generalized their skills to untrained combinations; and two participants showed less consistent evidence of learning. The effects, as measured during structured probes, were strong for one participant, moderate for another, and inconclusive for the two others. Responses during shared story reading suggested that the measurement probes might have underestimated participants' ability to combine symbols.

Support for AAC use in preschool, and growth in language skills, for young children with developmental disabilities

Little is known about how AAC use in preschool may impact language development for children with complex communication needs (e.g., children with autism, cerebral palsy, Down syndrome, and other developmental disabilities). We developed two surveys (a) to describe children's use of AAC in preschool classrooms, as well as the use of prompts and question asking, and augmented input by their communication partners; and (b) to describe teachers' experience, training, and perceived support in providing AAC. We then examined the relationship between children's experience of AAC, including the use of prompts, question asking, and augmented input by their partners, and the growth of receptive and expressive language for 71 children with developmental disabilities over a two-year period. The use of AAC by peers to provide augmented input was associated with stronger language growth; the use of prompting and question asking by teachers was associated with weaker language growth. Teachers reported that they received little training regarding ways to support a child's use of AAC. Results suggest the need for further research on promoting AAC use at the preschool level, including research to promote peer interactions for AAC users.

Reliability and validity of the C-BiLLT: a new instrument to assess comprehension of spoken language in young children with cerebral palsy and complex communication needs

In clinical practice, a variety of diagnostic tests are available to assess a child's comprehension of spoken language. However, none of these tests have been designed specifically for use with children who have severe motor impairments and who experience severe difficulty when using speech to communicate. This article describes the process of investigating the reliability and validity of the Computer-Based Instrument for Low Motor Language Testing (C-BiLLT), which was specifically developed to assess spoken Dutch language comprehension in children with cerebral palsy and complex communication needs. The study included 806 children with typical development, and 87 nonspeaking children with cerebral palsy and complex communication needs, and was designed to provide information on the psychometric qualities of the C-BiLLT. The potential utility of the C-BiLLT as a measure of spoken Dutch language comprehension abilities for children with cerebral palsy and complex communication needs is discussed.

Utility of language comprehension tests for unintelligible or non-speaking children with cerebral palsy: a systematic review

AIM

to identify the use and utility of language comprehension tests for unintelligible or non-speaking children with severe cerebral palsy (CP).

METHOD

severe CP was defined as severe dysarthria (unintelligible speech) or anarthria (absence of speech) combined with severe limited mobility, corresponding to Gross Motor Function Classification System levels IV to V. An electronic search in the databases of PubMed, PsychInfo, Embase, and CINAHL was made of studies published between January 1965 and December 2008. Indexing terms and free-text terms for 'cerebral palsy', 'language', and 'instrumentation' were used. Studies were included when (1) the focus was to investigate comprehension of spoken language of children (0-18 y) with severe CP, and (2) language tests were described.

RESULTS

twelve standardized tests and five experimental instruments were identified. All standardized tests were developed for children without limited mobility. Only the Peabody Picture Vocabulary Test - Revised was frequently used and feasible for older children with severe CP (> 9 y). The other tests were used occasionally. To establish utility, adaptations of standardized test procedures were necessary.

INTERPRETATION

language comprehension tests for children with severe CP are scarce. A language comprehension test specifically designed for these children is warranted.

Preschool-aged children have difficulty constructing and interpreting simple utterances composed of graphic symbols

Children who require augmentative and alternative communication (AAC) systems while they are in the process of acquiring language face unique challenges because they use graphic symbols for communication. In contrast to the situation of typically developing children, they use different modalities for comprehension (auditory) and expression (visual). This study explored the ability of three- and four-year-old children without disabilities to perform tasks involving sequences of graphic symbols. Thirty participants were asked to transpose spoken simple sentences into graphic symbols by selecting individual symbols corresponding to the spoken words, and to interpret graphic symbol utterances by selecting one of four photographs corresponding to a sequence of three graphic symbols. The results showed that these were not simple tasks for the participants, and few of them performed in the expected manner - only one in transposition, and only one-third of participants in interpretation. Individual response strategies in some cases lead to contrasting response patterns. Children at this age level have not yet developed the skills required to deal with graphic symbols even though they have mastered the corresponding spoken language structures.