Effectiveness of colored visual prompts for three word phrase development in intellectually disabled (ID) children

Abstract

Intellectually disabled (ID) children lack adaptive skills and have difficulty initiating conversation as they have deficiency in language areas. Also they have difficulty in verbal expression which is more prominent compared to receptive language requiring extra support. To improve language and memory retrieval, techniques providing optimum learning are essential. Color raises the probability of stimulus to be encoded, retained and remembered; hence this study was conducted with the aim to explore the efficacy of color coding approach for three word phrase development in mild to moderate ID children and to develop language at phrase level. This interventional study was conducted at Hamza Foundation, Rawalpindi, Pakistan over a period of six months. A total of 20 children diagnosed with mild and moderate ID fulfilling selection criteria were recruited through non probability consecutive sampling. Following assessment of nouns and verbs, three general culturally adopted phrases: boy eats apple, boy brushes teeth, girl washes hands; and three color flash cards: green for object, yellow for verb and orange for subject, were used for intervention in 5 steps along with language development form for monitoring. Intervention and monitoring of child performance was done in 6 sessions per phrase (2 sessions per week, each of 25-30 minutes duration) and response time noted. Mean time response was calculated and compared for all 6 sessions for all 3 phrases. Results revealed considerable decrease in mean response time of the children across all sessions, thus proving that color coding approach had positive effect on phrase development in mild and moderate intellectually disabled (ID) children. Also the approach was effective regardless of child's gender, age and severity of ID.

Headnote

Article history

Received 08 January 2019

Accepted 22 April 2O19

Early online 22 July 2019

Print 31 July 2019

Abstract

Intellectually disabled (ID) children lack adaptive skills and have difficulty initiating conversation as they have deficiency in language areas. Also they have difficulty in verbal expression which is more prominent compared to receptive language requiring extra support. To improve language and memory retrieval, techniques providing optimum learning are essential. Color raises the probability of stimulus to be encoded, retained and remembered; hence this study was conducted with the aim to explore the efficacy of color coding approach for three word phrase development in mild to moderate ID children and to develop language at phrase level. This interventional study was conducted at Hamza Foundation, Rawalpindi, Pakistan over a period of six months. A total of 20 children diagnosed with mild and moderate ID fulfilling selection criteria were recruited through non probability consecutive sampling. Following assessment of nouns and verbs, three general culturally adopted phrases: boy eats apple, boy brushes teeth, girl washes hands; and three color flash cards: green for object, yellow for verb and orange for subject, were used for intervention in 5 steps along with language development form for monitoring. Intervention and monitoring of child performance was done in 6 sessions per phrase (2 sessions per week, each of 25-30 minutes duration) and response time noted. Mean time response was calculated and compared for all 6 sessions for all 3 phrases. Results revealed considerable decrease in mean response time of the children across all sessions, thus proving that color coding approach had positive effect on phrase development in mild and moderate intellectually disabled (ID) children. Also the approach was effective regardless of child's gender, age and severity of ID.

Key words: Colorful semantics, Intellectual disability, Learning disability

DOI: 10.5455/jmas.25230

© 2019 Deccan College of Medical Sciences. All rights reserved.

In humans adaptive behavior is essential to learn routine social and practical skills for living and performing daily tasks independently. Intellectually disabled (ID) children lack adaptive skills i.e. communicating, socializing, self-care, job and educational skills, accompanied with below average IQ score (<70-75) before 18 years of age. Even milestones like walking and talking are delayed1. ID is quite prevalent (2-3%)2, and is categorized into 4 types from mild to profound depending upon the functioning level of the child1. A number of risk factors are linked to the etiology of ID with pre-natal as well as post-natal factors, including genetic causes as well2. Intellectually challenged children (ICC) show difficulty in initiating conversation and correct speech requiring extra support to live and succeed1.

Language development includes development of understanding and communication occurring in stages parallel to changes occurring in the functional brain organization which is also associated with performance related to language3. Mental disorders are categorized into 4 types from mild mental retardation (MR) to profound on the basis of functioning brain level. 85% of ID's have Mild MR (IQ score of 50-70), 10% have Moderate MR (IQ=35-55), 3-4% have Severe MR (IQ= 20-40) and 1-2% with Profound MR (IQ=20-25)1. Mental retardation is the most common cause of speech and language delay, including deficiency in language areas like word combination, grammar, formation of sentences, meaning and use of words as well as difficulties in verbal expression, as well as receptive language4.

Color is a powerful instrument which can be used at a number of places with many intentions, since it can draw our attention to the target and make things more clear. Therefore, colors are also used in schools for academics to improve learning. Red color is used by teachers for corrections in note books, since it draws our attention to the mistakes. Hence, colors are used since they raise the probability for stimulus to be easily encoded, retained and remembered5, thus it enhances memory and learning6,7.

Bryan8 developed colorful semantic approach and used this technique in a 5 years old boy, to show sentence structure/syntax. Hettiarachichi9 studied the effect of colorful semantics on narrative skills of ID children and found post intervention improvement, both in terms of qualitative and quantitative narrative skills. Color has also been reported to be a facilitating cue in a study conducted on children suffering from William syndrome with poor drawing ability compared to normal children10. Uccula et al11, in their review article reported that the effect of colored overlays on reading is controversial.

A method that provides optimum learning environment and outcomes to ensure best learning opportunities in ID to improve language and memory retrieval is required. Hence, this study was conducted to explore the efficacy of color coding approach for three word phrase development in mild to moderate intellectually challenged children. Previously this approach was used with severe specific language impairments. We used this technique in mild and moderate ID to develop language at phrase level. The current study has significant importance since there is dearth of literature on use of this technique in ID with no study from Pakistan.

Materials and methods

Approval was obtained from Advanced studies and research committee (ASRC) ISRA University vide reference number 1309-MPhil SLP & HS-002.

This Quasi experimental study recruited 20 children, using non probability consecutive sampling technique, fulfilling inclusion criteria from the Department of Speech and Language Therapy, Hamza Foundation, Rawalpindi, Pakistan over a period of 6 months (from 1st July 2014 to 31st December 2014). These included children of either gender aged between 6 to 10 years, who were diagnosed cases of mild and moderate ID children and were able to produce nouns and verbs independently, could understand simple verbal commands, and had vocabulary of at least 150 words or could speak two word phrases especially nouns and verbs to express their needs. Children with normal speech language developmental milestones or those having severe to profound ID were excluded from the study. As nouns are learned before verbs in typical language development12, in this study those phrases were selected in which nouns were already learned. Target of the study was to combine those nouns and verbs to produce phrases. With the hypothesis that colored visual prompts are effective for three word phrase development in mild to moderate ID children, study was conducted to analyze the efficacy of color full semantics in mild and moderate intellectually challenged children. For this purpose, three general, culturally adopted phrases (boy eats apple, girl washes hands and boy brushes teeth) and three color flash cards (green for object, yellow for verb and orange for subject) were selected.

After taking informed consent either from the caregivers / parents, assessment of vocabulary includ- ing nouns and verbs was conducted. A standard language development form was used as benchmark to compare normal language development stages at different ages. Colorful coding technique based on colorful semantics developed by Bryan8, was used to treat the children. Each child was given 25-30 minutes sessions twice a week. In this approach therapy was applied in 5 steps. First step was presentation of card of targeted phrase and at this level, we used one picture of verb and one picture of noun and the subject observed and listened to the investigator. In the second step same procedure was followed with one card of verb and for noun two options were given and asked about the target card i.e., what is happening in this picture? Subject chose the correct card of noun and placed 3 cards on sentence strip i.e., noun on green, verb on yellow and object on orange portion. In the third step investigator gave two options for verb as well as for noun, while demonstrating orally. The participant chose the right card and placed them on strip. In the fourth step the same procedure was followed with one card of noun and one card of verb and two options of objects were given. Subjects choose the correct card of object and placed 3 cards on sentence strip. In the fifth step, participant had to place the targeted cards on sentence strip and utter the target phrase when investigator presented him with visual target card. Same procedure was followed for all these phrases. If the child was not responding the investigator carried out gestures, signs and sound cues. Cues or prompting were used for the child to give a response and response time was noted using a stop watch by the investigator.

Performance of each children was monitored in 6 sessions per phrase (two sessions per week, each session comprising of 25-30 minutes) and response time of every child for each session was recorded. A total of 18 sessions per student were taken for 3 phrases. A bench mark of 15 seconds was set for each phrase on last session to determine whether the participants had learned, however a response after 15 seconds was considered a negative response.

Statistical analysis

Collected data was coded, organized and statically analyzed using SPSS version 21 (IBM SPSS, Chicago, USA). For categorical data like gender and severity of ID, frequency and percentage were calculated, while age is presented as Mean+SD. Variables specially studied included mean response time. Repeated measures ANOVA (RM-ANOVA) was used to find within group differences. The results were then compared with local and international literature.

Results

The sample population comprised of (N=20) ID children, with age range of 6 to 10 years. The mean age was 8.0+1.12 years including 14 (70%) males and 6 (30%) females with male female ratio of 2.33:1, with 11 (55%) children with mild ID and 9 (45%) with moderate ID (Table 1).

Figure 1 shows that from session 1 to session 6, the average response time for all phrases decreased session by session suggesting that the color coding approach has impact on the learning process of participants, thus bringing the response times down. Most of the participants learned phrases with increased time response initially but gradually it was decreased. In initial sessions participants were provided phonemic cues, gestures and signs after that they learned phrases without additional cues and support. Phrase 3 has relatively higher average response times as compare to phrase 2 (Fig 1). Only 1 participant in phrase 1 and two participants in phrase 3 failed to retrieve or learn the phrase 1 and phrase 3 respectively.

Repeated measures ANOVA (Table 2) to measure the differences in all 6 sessions revealed that the mean response time from session 1 to session 6 for all three phrases decreased session by session and dropped considerably from session 1 to ses- sion 6 with a statistically significant decrease in response time (p<0.05) proving that color coding approach has impacted on the learning process of participants. However Phrase 3 has relatively higher average response time as compared to phrase 2 because the phrase has a new word 'girl' in it whereas phrase 1 and 2 had 'boy' as a common word in them. The peak time response of Session 1 was 48 seconds for one participant who belongs to moderate category and his time response decreased through Session 6 to 9 seconds. Another patient with mild ID took 18 seconds in Session 1 of Phrase 1 and her response time highly decreased to 4 seconds in last Session. In Phrase 2 two participants with mild and moderate ID took 35 seconds in their Session 1 which reduced to 7 and 6 seconds respectively. In Phrase 3 one participant from moderate category took 35 seconds in Session 1 and his time decreased to 18 seconds. One participant with moderate category did not learn Phrase 1 as he was not able to achieve the targeted Phrase in fixed time duration. Phrase 2 was achieved by all participants with reduced or decreased time. Two participants with moderate category could not learn Phrase 3 as evident with a time response exceeding 15 seconds.

Comparison of results of 3 Phrases with each other across the 6 sessions (Table 3) revealed a statistically significant relation between Phrase 1 and 2 due to difference in the response time in all 6 sessions, due probably because Phrase 1 and 2 had almost similar words in them. On the other hand the difference was not much significant between Phrase 1 and 3 and Phrase 2 and 3. This may be because Phrase 3 had a different word 'girl' in it as compared to Phrase 1 and 2, thus participants had difficulty in learning the Phrase 3 as it was relatively new to them.

Effect of gender, age and severity of ID on color coding technique was also studied (Table 4), and it revealed that age, gender and severity of ID had no statistically significant (p>0.05) effect on color coding approach on participants and the technique shows its applicability irrespective of age, gender and severity of ID, though gender wise girls performed better in achieving three Phrases compared to boys.

Phonological deficits were noted while producing Phrases. Especially in Down syndrome children, errors were noted in production of 's' and 'sh' sounds. Other phonological errors were noted like 'wash' was substituted with 'gosh'. One participant with moderate ID substituted 'eats' with 'beats'. Some changed the order of the Phrase during sessions. Color coding approach boosted memory with visual support which in turn strengthened working memory. In initial sessions participants were provided phonemic cues, gestures and signs after that they learned Phrases without additional cues and support and produced target Phrases. Only 2 participants could not learn last Phrase due to memory deficits.

Discussion

This interventional study analyzed the efficacy of color coding approach for three word phrase development in mild to moderate ID children. Intervention using color coding technique was applied and most of the subjects learned the target phrases at their time and response time decreased slowly. Approach involving intervention and monitoring in 6 sessions revealed a statistically significant (p<0.05) decrease in the mean response time from Session 1 to Session 6 for all three phrases, proving that the color coding approach positively impacted the learning process of participants. Similarly a number of studies support the effectiveness of colorful semantics method8,13,14.

Bryan8, developed "colorful semantics" approach and used it with severe language disabilities or impairments. She used this approach to show sentence structure/syntax. This technique showed expressive language improvement 12-18 months after three months of intervention8. Bolderson et al14, conducted study in clinical settings to see progress in 4 and 6 years-old-children, using the tools like the Bus story, Renfrew Action Picture Test, the Test of the Reception of Grammar and informal verbal assessment. Therapy was provided 2 times in a week for 2 months followed by post intervention assessment which revealed improvement in all parameters except the use of verb and grammar for making sentence did not improve14. Hittiarachchi9 also concluded that the colorful semantics approach is an effective therapy approach to support development of narrative skills in children with intellectual difficulties. In the current study, color coding technique showed its applicability irrespective of age and was equally effective in all age groups.

Shah et al stated that in 133 cases, 82% mentally retarded children were found with speech and language issues and male to female ratio was 2:115. Similarly the male female ratio in the present study was 2.33:1 and the girls showed much better performance in achieving three phrases as compared to boys, however this difference was not statistically significant.

Additionally in this study, phonological deficits were also noted while producing phrases especially in Down syndrome children, errors were noted in production of 's' and 'sh' sounds. Other phonological errors were like 'wash' was substituted with 'gosh'. One participant with moderate ID substituted 'eats' with 'beats'. Some changed the order of the phrase during sessions. Intellectually challenged children have short term memory and poor retrieval issues16. Color has positive influence on memory17, and in this study color coding approach boosted up memory with visual support in turn strengthened working memory. All subjects produced target phrases without any non verbal cues and gestures. Only 2 participants could not learn last phrase due to memory deficits.

Limitations

Limitations of the current study were that the sample size was small and study limited to one institute only.

Conclusion

The present study shows that color coding approach has direct and significant positive relation with the phrase development in mild to moderate intellectually challenged children irrespective of age and gender. Visual colored prompts are effective for learning and memory.

Acknowledgments: None

Source of funding: None

Conflict of interest: None to disclose

References

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