Group approach for the evaluation of language disorders in young children

The aim of this study was to describe the contributions of a group therapy approach, which had a social interactionist focus, on the evaluation of language in children aged from between one year, nine months and three years. Nine children participated in the study and they were evaluated in three groups of three participants (G1 and G2 children with language disorder problems, G3 children without language disorders). Four video-recorded meetings were performed for each group, each of which lasted from 30 to 60 minutes. The videos were analyzed along with the field journal, focusing on the participation of the children and their oral and non-oral production. This study provides a detailed analysis of G2, which showed an increase in oral production and an expansion of linguistic functions throughout the sessions. The non-verbal aspects contributed to the identification of relevant elements related to language, especially at the pragmatic level. The context of play and group interaction, and even disputes for objects, led to the detection of different aspects of language. The proposed assessment which is described made it possible to observe the children’s language in a live context and it is a model that covers the different aspects of language in meaningful contexts of interaction.


introduction
There has been a growing demand in speech therapy clinics for care for children who have been referred with speech disorders [1][2] .The first procedure performed by the speech therapist is an assessment, which is a process designed to characterize and analyze the child's language in order to define the correct treatment.
In the process of language assessment, the procedures which are adopted must be able to provide support for the conduct that the professional will undertake 3 .These procedures include gathering information from interviews with those responsible for the child; the observation, recording and analysis of the physical, mobility, relational, hearing and language aspects of the individual and the context in which they are situated; and a comparison of the data observed in the individual with established standards, which are based on research and analysis of the socio-cultural context.Thus, the evaluation of language gives the professional the opportunity to investigate developmental characteristics and also to propose hypotheses about the linguistic aspects of the case in order to define the focus of intervention.
The methodology used in the evaluation depends on the theoretical framework adopted by the evaluator.This study is based on a social interactionist approach, which considers that language occurs through social interaction in exchanges between social partners and through mediation processeses [4][5][6] .With regard to language acquisition, the social interactionist perspective considers that social, communicative and cultural factors are key to the acquisition of language 7 .The process of language acquisition is considered to be a consequence of the dialogic relationship between adults and children 8 .
The social interactionist approach to language acquisition favors the use of assessment methodologies in which the observation of children's language occurs in meaningful contexts of interaction.These contexts emphasize dialogic and interactive processes, and they provide diverse possibilities for interaction between adults and children, preferably in groups.The evaluation of language in a group context is interesting from a social interactionist perspective because it is a context in which communicative exchange can be observed between various partners 7 and also because it occurs in an environment of social interaction 9 and games, a situation that children are constantly exposed to.In the area of speech therapy, a clinical model has predominated, with a unitary relationship between therapist and patient.However, the group work approach has also been used since the 1980s.In Brazil, this type of approach was first used in public services due to increased demand for care in the Basic Health Units.The group approach became used in therapy in order to assist a larger number of people 9 .Once this resource started to be used professionals began to see that it had other benefits and groups were seen as an important opportunity to exchange knowledge and feelings 1,10 .In addition to meeting economic and organizational demands, the group approach constitutes a form of work that can contribute to the emergence of language in all its dimensions and it favors the construction of processes that facilitate the development of language and subjectivity.Groups provide different possibilities for relationships, in which participants can exchange information, experiences and knowledge [11][12] .Regarding the role of the speech therapist in groups, it is considered that the latter should be the mediator and interlocutor because language should be used as an expression of the participants and their needs 13 .
Even taking into account the positive aspects of group work, the latter is still seen as a challenge in the field of speech therapy 14 .This is despite the fact that it is an approach which has been used by other professionals who adopt a social interactionist methodology 15 .Realizing that language constitutes and manifests itself in social interactions and dialogical relations, these professionals opt to use group work because it is a space in which the phenomena that characterize language are present.
After the construction of a group and the identification of its participants, one of the studied phenomena than is usually observed is the bonding and familiarity among participants.The concept of bond is always social and it is understood from the perspective of the contact between the different stories of interpersonal relationships of the participants of the group, which are formed by bonds of space and time [16][17] .
In a literature review that was conducted of articles that addressed the issue of group therapy in speech therapy 18 , the area in which most studies were published was found to be that of language.Regarding the public that were attended in groups, most were adults followed by children.With regard to studies that have evaluated children's language, one of the criticisms of the traditional approach is that an assessment along these lines tends to provide only partial and incomplete information about a child's capabilities because children do not feel at ease in front of an adult who is practically unknown to them 19 .On the other hand, it is considered that evaluation conducted in a group allows the observation of the manifestations of language with different interlocutors.Group meetings, if they are repeated several times, allow for the formation of rapport and bonds between the members, and also the possibility that children will feel more comfortable to display their potential and their language.
One of the studies of language assessment, in which aspects related to group work were considered in the evaluation process, was that of Laplane et al. 20 .The aforementioned study reported on an internship within a speech therapy course that incorporated a language group.During this language group the children were observed in groups while playing; this was the chosen strategy that was intended to promote interaction and the emergence of language.
The studies cited above emphasize the importance of the group as a context in which to work with speech therapy, which is especially relevant when the social interactionist concept of language is adopted.In line with these principles, the aim of the present study was to describe the aspects and contributions of a group approach in evaluating children's language within an age group of 21 to 36 months.

Methods
This is a qualitative study 21 and the research was approved by the Research Ethics Committee of a public university.Throughout this study, the children's names, when cited, have been replaced by fictitious names.In all the cases where it was suggested that participants should be referred for speech therapy evaluation or treatment, arrangements were made for appropriate care after the study ended.

Participants
Nine children, who were aged between one year and nine months and three years, participated in the survey.They were divided into three groups; Groups 1 and 2 were formed by children with language disorders, and Group 3 included children without such complaints.The number of children with language disorders and without such complaints was differentiated because in the group without language disorders it was hoped that that there would be a lower variability in responses, which did not require the equilibrium of participants between the groups.The choice of children with and without language disorders was made in order to ascertain whether the assessment methodology proposed in this study would be applicable and if would be possible to observe social interaction between all the children, whether they had language disorders or not.
The children in Groups 1 and 2 were identified through a university health service, in which an internship from the speech therapy course at the University of Campinas (Unicamp) was taking place.Some of the children had diverse backgrounds in terms of diagnosis/complaints, including genetic syndromes, neurological disorders, sequelae of prematurity, etc.Other children only had complaints related to language delay and/or difficulty, which had been identified by the family, school or health service.These children were selected according to the order in which they were situated on the waiting list for the service.
The children in Group 3 were identified in a public kindergarten in the same municipality.The requirement for participation in the study for this group was an absence of language complaints or a history of severe health problems, especially those related to possible risk factors for hearing loss and neurological problems.The parents of the children agreed to their participation and the children themselves had a regular attendance record at school.
Chart 1 provides a brief characterization of the participants of Groups 1, 2 and 3. Information obtained by those responsible for the children are identified by the abbreviation (R), and the data obtained from the health service reports are identified by the abbreviation (S).

Data collection
The children were evaluated in three groups, each group with three participants.There were four meetings, which lasted 30 to 60 minutes, for each group.
The interview with those responsible for the children was conducted in a semi-structured way, based on a script that focused on the following aspects: the child's birth conditions, family constitution, psychomotor development, and language and auditory development.
In the rooms where the meetings took place, all the participants and the researcher remained sitting on a mat on the floor, which was where * age at first group assessment.

Diagnostics/History
Born prematurely and remained in hospital for 16 days to gain weight and to become accustomed to light (R).
Did not show organic commitments.
Referred for speech therapy assessment by the pediatrician due to maternal concern about the child's language.
Born prematurely and remained in hospital for 21 days because of anoxia and anemia due to blood loss (S).Displayed delays in neuropsychomotor development (NPMD), took longer than normal to crawl and did not walk at the time of assessment.
Referred for speech therapy assessment by kindergarten teacher.
A year previously he had been taken away from his parents and he was living in a shelter.When he was living at the shelter he had anemia and worms (R).
Did not show organic commitments.Spontaneous request from the shelter for speech therapy assessment.the activities took place that led to the observation of the interaction in relation to the language assessment.Toys, books and materials were made available; these were commonly used for the age group of the participating children, and they were probably present in their home and/ or school context.The toys were located near the children and they could take them when they wanted.If a child did not show any inclination to take the toys, the researcher encouraged them to play with them.From time to time there were activities directed by the researcher which were intended to observe important aspects regarding the characterization of language.All the meetings were video recorded using a digital camera (with tripod support or hand-held by a speech therapy intern) and the data from the sessions were also recorded in a field journal.

Analysis of data
The recordings were examined repeatedly in order to describe the children's participation in the sessions, as well the children's oral production in each session.Transcripts were made of significant episodes and notes were made of all of the oral production of each child.We sought to characterize the child's language and their participation in the group.The language was analyzed in oral and non-oral terms, and the participation of the child was analyzed throughout the four sessions.

results
As an example of the analysis carried out in groups, the evaluation of the children participating in Group 2 will be described.Kaio was the participant who remained most removed from the group but occasionally he interacted with the others.Eduardo's participation mainly consisted of looks and smiles during the activities, which was largely due to limitations in his mobility in the upper and lower limbs.Murilo showed the greatest initiative to play with the other children and he gave objects to Eduardo and Kaio.
Given that the main problems of the children in Groups 1 and 2 were related to language delay /difficulty, a survey was performed of the words and utterances used by the children throughout the sessions, which was aimed at analyzing their production environment as part of the analysis of their participation in each session.
Chart 2 shows all the examples of oral language from the children from Group 2 during each group session.This is followed by a description and analysis of the context in which they were produced, as well as the other forms of participation and use of non-verbal language of the children during the sessions.
Chart 2 shows that there was a tendency for increased use of oral language throughout the sessions: Kaio presented an example of oral language in the last session, Eduardo presented some examples of oral language in sessions 3 and 4 and Murilo showed an expansion of language functions throughout all the sessions.
A more detailed description of Chart 1 is provided below.This presents the results for each child and contains a summary of the interview with the person responsible for the child, a description of the child's oral and non-oral language production, and an overall assessment and proposals for the future.

Kaio
Interview: the child's mother reported that he had been referred to the speech therapist by the pediatrician "because of speaking -he still doesn't speak."He did not attend school and had little contact with other children.When he was in the company of other children he preferred to play alone.
Oral language: the first oral production of the child ("ah ah!") was observed in S4.Murilo was in front of Kaio, blocking his passage to the door, and the end of the session had been announced.Kaio probably shouted "ah ah!" to get Murilo to move out of the way so that he could leave the room.The production had the intensity and intonation characteristic of an order.Kaio did not produce oral language in the other sessions, and at the end of the last session he produced a vocal statement vowel with a clear intention, i.e. to resolve a situation that was impeding him from leaving the room, which was caused by another member of the group.
Group interaction and language manifestations: during the sessions, Kaio mainly preferred to play with the toys in corners of the room; he rarely interacted with the adult and the other children.His visual contacts were few and they occurred in an unsystematic way.When he looked at his interlocutor he rarely responded to speech with either oral or non-oral language.One of the times when it was possible to observe non-oral language occurred in S2.In this episode, Kaio, who for most of the session kept away from the rest of the group with his face to the wall, showed interested in the activity using pieces of Lego ® .Kaio made eye contact with the researcher (the adult who proposed the activity) when placing the piece inside the box.He watched the way in which the adult and the other children placed the pieces and he then followed their example with his own piece of Lego ® .It was observed that the group aroused Kaio's interest in an activity other than that he was performing.The involvement of the participants in activities and the group context were important in arousing the interest of this child in the game.This caused him to stop to exploring other objects in the room and turn his attention to the game that the others were playing.He also followed the same mode of behavior as the other children.In S4, Kaio used a different form of language; in addition to the use of non-verbal language he said "ah ah!" to another child to try to get him to move out of the way, thereby presenting a discursive initiative.
Conclusion of evaluation and recommendations: the information provided by Kaio's mother, i.e. that Kaio preferred to play alone even when he was in the company of other children, was consistent with the observations made in the sessions.Kaio had unsystematic eye contact, he used gestures infrequently, his lexicon was limited to a vocal sound, and it was difficult to know if he understood what was said to him or shown to him (he did not make an action or response to show if he understood so it was unclear if he made an action because he did not want to participate in the play activity or if he misunderstood the request).All these factors indicated a level of language development which was different from that which would be considered typical for his age.At the same time, potential were observed; for example, when he paid attention to the way in which other participants handled the object and he then reproduced the same be-havior.Because of this it was recommended that Kaio be appointed a speech therapist specialized in the area of language and that he attend school so that Kaio might have more opportunities to interact with children of his age group.eduardo Interview: Eduardo is an only child and his mother had complications during her pregnancy with him.The pregnancy was twins, but due to complications only Eduardo survived.He was undergoing physical therapy (twice a week), respiratory therapy (twice a week) and he was about to start occupational therapy.He was not attending school; the family had made two attempts to get him into a school but he contracted viruses so his parents decided to take him out of school.Eduardo had a delay in neuropsychomotor development and was unable to sit or walk without support.In relation to language development, his mother reported that he only spoke two words: "papá" (father) and "boba" (referring to his mother).She considered that he understood what others were saying and that he was always looking at other people and laughing with them.
Oral language: at the beginning of the sessions Eduardo rarely issued sounds, as shown in Chart 2. As the sessions continued, and due to greater contact and interaction with the group, he began to show greater discourse initiative with unintelligible sounds and a few words.In S3, Eduardo made his first sounds in the context of an imaginary phone call; these were "papá" (daddy) and "boba" (referring to his mother)."Papá" was said when Eduardo had the phone in his hand after a game in which the adult said he that he would call his father.By saying "papá" Eduardo was possibly using a dialogical process (specularity) when he repeated the speech of the adult who had just said "daddy."Eduardo said "boba" during the play telephone call after saying "papá".Eduardo began to handle the phone again and said "boba".When the researcher asked if he was talking to his mother, he smiled.In this incident the first member of the group to participate in the make-believe was Murilo.After Eduardo watched him for a while he started joining in as well, including producing his first words in the context of the evaluation.In S4, when the researcher stopped making soap balls, Eduardo said "boia", as if he was asking for the game to continue.Eduardo therefore used oral language to regulate the action of the researcher, also demonstrating a greater variety of language functions throughout the sessions with the group.
Group interaction and language manifestations: Eduardo was a very sociable and observant child, always attentive to activities that took place around him and the children who interacted with him.Gestures are not described in the table but they were of the utmost importance in Eduardo's case; he used them at various times, especially the proto-imperatives (when a child gestures to an adult to do something for them, to get a toy for example).In S1 and S2, Eduardo constantly pointed in order to request and show objects.In S3 and S4, Eduardo used social gestures, such as waving goodbye and blowing kisses to the group, thus demonstrating a familiarity with the other children and the researcher, and also highlighting his social skills.In the early sessions (S1 and S2), Eduardo communicated through eye contact, smiles and pointing gestures.An example of such participation occurred in S2.The child who had mobility problems always participated in the games through eye contact and facial expressions.He accepted the help of the researcher to participate in the activity with the Lego ® .Eduardo not only accepted the help but then he also wanted to accomplish the task himself and in one of his attempts he managed to put the Lego ® piece in the box.The involvement of the other children in the activity seems to have aroused the interest of Eduardo in trying different moves and to participate more actively in the play activities.
Conclusion of evaluation and recommendations: analyzing the data related to Eduardo it was considered that he showed a different type of development than the literature considers typical for a child of his age in terms of the language aspects that were observed and that he also presented indications of development.Because of his individual language requirements it was recommended that Eduardo have access to speech therapy.It was also recommended that he participate in group activi-ties with few children so that he would have greater opportunities to interact with children of his age.

Murilo
Interview: Murilo is an only child.He was born with renal impairment and problems in the lower urinary tract and the large intestine.Because of these problems Murilo had to undergo six operations; since the last one (which was three months previously) he had not needed any artificial help to urinate or defecate.At the time of the study he was not on any medication and according to his mother he was leading a "normal" life.His contact with other children was restricted and he occasionally visited a cousin of about his own age.One of the conditions for him being accepted in a school was that his colostomy be removed.Once it was removed his mother tried to find a public kindergarten to enrol him but without any success.Murilo started talking at the age of 20 months but according to his mother his vocabulary was very limited and because of that she had contacted the speech therapy service.
Oral language: In S1 Murilo produced oral language to indicate the location of objects ("aki ó") and to call the researcher's attention for toys ("oia").In S2 he said "oia aki ó" and "oia aki" to order to attract the attention of the researcher and the other children.Another process observed in S2 was specularity; immediately after the researcher had spoken the words "do outro lado" during the game involving Lego ® Murilo said "co oto ado".This statement by Murilo appeared to be a "mirror" of adult speech.This also occurred when the researcher said that the piece of Lego ® "caiu" and Murilo said "aiu".In S3, when the objective of the play activity was to put the Lego ® pieces into a lorry and say the colors, the researcher said "azul" (blue) and Murilo speculated his speech saying "aul".The color that Murilo said without any prompting was "vermei" (red).In the same session, Murilo also produced a statement that was typical of imaginary play with a telephone -"aô, quem é" (hello, who's there?).In S4, he said "oia aki ó" to attract the attention of the researcher and when the researcher asked him questions about the name of the object, its color, and what he was doing, Murilo replied "kao" (car), "vermei" (red) and "koe" (run).It was therefore possible to observe a more complex use of oral language throughout the course of the sessions.
Group interaction and language manifestations: Murilo was a very active child, exploring the whole environment, toys etc and interacting with adults and children.He also helped Eduardo, who had physical difficulties in handling the toys, and showed him how to put the phone in his ear.He maintained visual contact with all his interlocutors and alternated oral language with gestures but his most common means of communication in the sessions was oral.Murilo showed an understanding of the context of the games that were developed and the words that were addressed to him.In relation to his production, it was observed that he used words and short phrases that were always appropriate to the context and the games; for example, when he said "aô, quem é" (hello, who's there?) when placing the phone to his ear.His lexicon was used to refer to objects, to name colors, to speculate adult speech, to call the researcher and to participate in games of make-believe.Murilo also used conventional gestures such as nodding his head vertically to say "yes" and pointing to request the interlocutor's attention to distant objects.A strong bond was established with the researcher and Murilo came to say goodbye and sent kisses at the end of the sessions.
Conclusion of evaluation and recommendations: Murilo presented adequate language development for a child of his age in almost all the evaluated items.He made phono-articulatory exchanges that were expected for his age and his lexicon contained a slightly lower range of words than normal.Because of this it was not felt that speech therapy was justified in his case.Consequently, the benefits that he would gain by being enrolled in school were highlighted and a new speech therapy assessment was arranged for six months later.
The analysis of Group 1 was similar to that of Group 2. In Group 1 the oral production, and also its complexity, expanded throughout the sessions.The analysis of the production of non-oral language made it possible to identify examples of linguistic capabilities, and the interaction among the children was greater than was observed in Group 2.
In Group 3 the interaction between the children was more intense and diverse than in Groups 1 and 2. From the first session the production of oral language was more wide-ranging and it modified throughout the sessions.In the final sessions the children used more complex language that in the early sessions.

Discussion
The evaluation of language in a group setting made it possible to perform observations that would hardly be detected in situations with a unitary relationship (therapist-individual patient).An example of this was the discursive initiative when Kaio shouted at Murilo to get out of his way (S4).Other examples included situations in which Eduardo went on to participate in activities after Murilo had done them first.The group constituted a space that favored interaction, which enabled the identification of the linguistic potential of the children.Group evaluation, involving adult-child interaction, child-child interaction, and the provision of objects for interaction, provided the opportunity for observation of language in a broad sense 22,23 .
By observing children in interaction with others of the same age group it was possible to note the cooperation between them.Children with less difficulty helped others, especially the children with mobility difficulties, to handle, deliver and position objects.An example of this was when Murilo took the Lego ® block (which was intended to represent a telephone in the game they were playing) and placed it to Eduardo's ear because Eduardo did not have the physical capacity to pick up the object and put it to his own ear.The observation of the interaction and cooperation among the participants was indicative of sociability and the children's developmental potential, both in terms of those who offered help and those who accepted it 4 .In an assessment, the detection of these events is relevant for the characterization of the oral language of a child, as well as the context of social relations.
In the group context it was also possible to note that some children followed the examples of others, both in the mode of use of objects and also in the reproduction of words.Some children observed the way in which other children used a toy and then repeated it.In doing so, the children showed the skill of being attentive to others; the ability to understand what the other children were doing and to perform the same action as the others.
In the group setting some children sought contact with others using various resources, and not always by using oral language, as was the case of Eduardo.The search for interaction with peers is an important social marker 24 and it is possible only in a group context.In Group 3, where oral language was very present, the importance of evaluation in a group context was also noted.An example of this was the oral production of Anne, which was predominantly directed at Oscar, and which permitted the observation and characterization of language forms in a child-child interaction that was naturally different from the relationship with other adults 23 .By relating these findings to the language approach that was used, which focuses on the social element that is strongly present in a group, the role of the other is emphasized, as well as the mediation of adults regarding the acquisition and manifestation of language.Language occurs through the interaction with another speaker of that language, through communicative exchanges, through the significance of what a child says to another person, and through the mediation that occurs in relationships [7][8] .Even the situations involving disputes between the children in this study turned out to be important for the assessment of language.In several instances it was observed that a child pointed to a toy that was being handled by another child.If the session had only been between one child and a researcher the toys would not have been shared and the need to indicate the object might not have arisen.Disputes for objects occurred at various times during the sessions and they were one of the main contexts in which the children produced language to express their intentions to have the object and/or dialogue with each other and with adults in order to get those objects.Consequently, the group setting generated disputes, and these in turn proved to be interesting moments for the observation of oral language (as communicative initiatives and turn-taking) and non-oral language.
The possibility of interaction with different interlocutors, and in different contexts of play, meant that the oral language that was produced had different purposes and functions, such as naming, social interaction, ordering and indicating the location of objects, among others.For professionals who evaluate a child's language it is important to know about the language and vocabulary that the child uses in situations of interaction.
By assessing the children in a larger number of sessions it was possible to observe an increased complexity in the language functions used by the children.In the early sessions the language was mainly used to ask for objects and by the final sessions language was also related to interacting with other participants.One factor that may have influenced this change in the manifestations of language was familiarization, and the start of the establishment of a bond between the child and researcher, and between the child and the other children 25 .The evaluation of a group assumes a longitudinal aspect; time is required in order for there to be familiarization and the establishment of bonding.In the present study this was important in terms of increasing social interaction and for the manifestation of language to occur.These findings are in line with the social-interactionist view of language [7][8]23 , in which familiarity with the context is essential for the observation of language in a situation that is closer to the real production environment. Cosidering that language is one of the main demands of children 26 it is important that health professionals are aware of the reception, evaluation, referral and therapy that are used.

Conclusion
Group evaluation allowed the speech therapist to assess the children's language during interaction and also provided the opportunity to observe the following: the relationships between child-child and child-researcher; the different types of relationship the children had with other children and with adults; the dispute for objects, which often led to the production of oral and non-oral language; the cooperation among the children; the use of different functions of language (naming, requesting objects, informing actions, characterizing objects and social interaction); and important linguistic aspects such as communicative initiative and turn-taking.Thus, group evaluation group made it possible to observe language as a living exercise in the context of social interaction.
The concept of language that was adopted shaped the data collection within a naturalistic situation, recognized and valued the interaction within the group, and made it possible to give meaning to the expressions of oral and non-oral language, especially with regard to the children who demonstrated the most significant changes.In terms of the evaluation model to be adopted by health services, a greater number of sessions were recommended than usual, but the group context made it possible to attend a number of children simultaneously.It is worth pointing out that an evaluation that establishes bonds and that contains the possibility of identifying different language skills in a child, tends to reduce the risk of unnecessary referrals to different health services and special education services.
The group-based language assessment set out in this article allowed for observation with different interlocutors and in several sessions; it also covered different aspects in meaningful contexts of interaction.