COGNITIVE-LINGUISTIC SKILLS AND THEIR RELATIONSHIP WITH RESPIRATORY CHARACTERISTICS

(1) Phonoaudiologist at Hospital das Clínicas, Belo Horizonte, Minas Gerais, Brazil; Specialization in Language by CEFAC BH; Master in Bioengineering by UFMG. (2) Phonoaudiologist at Clínica Auto-Estima, Montes Claros, Minas Gerais, Brazil; Specialization in Language by CEFAC. (3) Phonoaudiologist at MedCenter Hospital Dia, João Monlevade, Minas Gerais, Brazil; Specialization in Language by CEFAC BH; Audiologist specialist by PUC/Minas. (4) Phonoaudiologist; Adjunct Professor from the Department of Phonoaudiology at the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; PhD in Human Communication Disorders by UNIFESP/SP. (5) Phonoaudiologist; Professor of the Phonoaudiology course at Methodist University Center Izabela Hendrix and the Specialization Course in Language at CEFAC-BH, Belo Horizonte, Minas Gerais, Brazil; Post-PhD in Linguistics by Laboratoire Parole et Langage – France; PhD in Linguistic Studies by UFMG.


INTRODUCTION
Among the most common respiratory disorders, especially among students, there is mouth breathing.Being considered a pathological adaptation to the difficulty of breathing through the nose, mouth breathing prevents the heating, humidification and filtration of air that reaches the lungs 1 .
The most frequent etiologies related to oral breathing is obstructive and/or pharyngeal nasal.The decrease in strength of the orofacial muscles can also lead to lack of labial sealing, and may cause a functional mouth breathing (when there is no mechanical obstruction) 2 .
There are numerous features that accompany mouth breathing, leading to the need for a multidisciplinary care to patients diagnosed with this ABSTRACT Purpose: to relate respiratory characteristics with cognitive-linguistic skills performance of children from a public school of the region of Belo Horizonte.Method: a cross-sectional, observational and descriptive study.From the 180 enrolled children, 131 met the inclusion and exclusion criteria.We evaluated 66 children in the 4th grade and 65 children in the 3rd grade of the elementary education, from both genders, with ages going between nine and ten year old.We utilized a questionnaire for assessment of respiratory characteristics and a previously published protocol and adapted to the Brazilian population in order to assess the cognitive-linguistic skills.Data were analyzed using the Mann-Whitney and Kruskal Wallis test at a significance level of 1%.Results: there was not observed a p-value <0.01 in comparison between the respiratory characteristics and the cognitivelinguistic skills' score obtained by each series.We observed that 59.1% of students had scores in a questionnaire for assessment of respiratory characteristics between zero and four points, indicating some impairment in respiratory variables studied.We obtained a significant p value for comparisons between the performance in cognitive-linguistic skills and the presence of respiratory disorders in the studied series.Conclusion: no significant relationship was found between the performance of cognitive-linguistic skills and the presence of respiratory characteristics in students from the same public school of Belo Horizonte city, and the children who showed respiratory changes didn´t have performance below those without these changes in the assessed skills.KEYWORDS: Learning; Education Status; Learning Disorders; Mouth Breathing skills should necessarily be previously acquired or developed 19 .In the comparison between the performance of children with respiratory disorders and those that do not express these complaints, it is observed that the first group presents greater difficulties in performing phonological awareness skills, these skills are precursors of a good development of reading and writing 20.21 .
Changes introduced as a result of installation or permanence of a respiratory disturbance framework lead to health problems, facial growth and behavioral changes can also affect student learning 22 .It is described in the literature that respiratory changes are common in school-aged children and which highly complex skills are precursors of the learning process.
Thus, the aim of this study was to assess the cognitive-linguistic skills of children from a public school in Belo Horizonte and relate the performance of these skills with respiratory characteristics of the students.

METHOD
This work is characterized as a transversal, observational and descriptive study.

Sample
For this study it was assessed children of both genders, aged from nine to ten, from 4th and 3rd grade of elementary school, 5 th and 4 th school year, respectively.All children were from the same public school in the city of Belo Horizonte, Minas Gerais.
It was considered as exclusion criteria children who had any syndromic and/or neurological change as well as sensory changes such as auditory and/or visual damage.For inclusion, parents or guardians should respond to the Questionnaire for Assessment of Respiratory Characteristics (QARC) (Figure 1) and signing the informed consent form (ICF) agreeing with the participation of their child in the study.disorder 3 .Among these changes it is described postural problems 4,5 , allergic conditions, olfaction 6,7 , snoring and sleep disorders 8 .Other effects commonly reported in studies involving oral breathing children is the presence of deleterious oral habits 9 , orthodontic changes and orofacial structures such as the tongue and lips 10 .
During sleep breathing discomfort is increased in the mouth-breathing children.In children with apnea sleep all the sleep cycle is altered.During the day, they can present aggressive behavior, symptoms of hyperactivity, attention deficit and cognitive and intellectual problems that will interfere in school learning 11 .In a study in which we assessed the problems related to sleep-disordered breathing, mouth breathing was one of the most common disorders 12 .
According to some authors respiratory disorders in children can lead to impaired growth, neurocognitive deficits, and less frequently, cardiovascular changes 13 .It is described in the literature that patients with nocturnal respiratory disorders may show a decrease in cerebral vascular flow during episodes of apnea 14 .Researchers also show that the most severe respiratory changes presented both in children and in adults is obstructive sleep apnea, where individuals have difficulties in cognitive functions reflecting negatively on life quality 15 .
The complaint of parents of mouth breathing children having difficulties in school is also common.A study through questionnaires to parents and teachers, found that sleep disorders lead to inattention, hyperactivity, impulsivity, and naps during class.Among children who had changes in the assessed skills, most of them also presented oral breathing 16 .However, in a study in which children were assessed in a social project in the state of Pernambuco it was not found a significant association between respiratory pattern and behavioral changes such as hyperactivity or inattention 17 .
Learning is a complex process that requires children to use phonological components, syntactic and semantic of the language 18 .For the child to go through the school process, a series of abilities and 65 children who were in 3 rd grade of elementary school.

Questionnaire for Assessment of Respiratory Characteristics (QARC)
Importantly, in this study we investigated possible signs and symptoms of oral and nasal breathing children.The participants were not classified as oral or nasal breathers, since obtaining this diagnosis must necessarily be carried out by a multidisciplinary team.To obtain information regarding respiratory characteristics of each student, a questionnaire was proposed in the literature 23 .The questionnaire consists of 22 closed questions, which were answered by parents or guardians.The responses were stored in a database and then compared with the scores obtained in PHCL.
At first the researchers approached the children participating in the study in their respective classroom, with the consent of the coordination of the school and the teacher.The objectives and methodology of the research were explained, and at the end, 180 children from the 4 th and 3 rd grade were given a consent form and QARC to take and present to their parents.Every classroom which had students in the 4 th and 3 rd grade was included in this research.
After two days from the delivery of the forms, the researchers returned to the school for the application of Protocol of Cogntivo-Linguistic Skills (PCLS) in those children who had signed the consent form and the QARC answered by parents or guardians.
Out of the 180 children invited 131 met the inclusion and exclusion criteria of this study.Thus, the sample consisted of 66 children in the 4 th grade and

Statistical analysis
The collected data were entered into a structured database in Excel ® and analyzed using the PASW Statistics 18 statistical program.The descriptive results were obtained using frequency distribution for the characteristics of the various categorical variables and obtaining measures of central tendency (average and median) and measures of dispersion (standard deviation) for quantitative.
For comparison between measurements scores (alphabet, copying, word dictation, pseudowords dictation, math, memory and total score), according to the grade level, we used the Mann-Whitney nonparametric test and compared following the questionnaire score (number of questions "yes") was employed the Kruskal Wallis non-parametric test, since the data is not normally distributed.It was established as p <0.01 for statistically significant correlations.

RESULTS
Table 1 describes the comparison between the scores obtained at PHCL according to the school grade.In this you can see the comparison between the scores obtained in each area surveyed and the total score.There was a significant difference (p <0.01) in scores between the grades in mathematical domains, dictation of words and total score.It was also evaluated the usual position of the lips, by observing the child for five minutes on a distracting task.The observation of lip closure was performed individually for each child during the application of PHCL by two different researchers from the one responsible for the direction of the application of the test.The presence or absence of labial sealing was recorded in the QARC for subsequent statistical analysis.

Protocol of Assessment of Cognitive Linguistics Skills (PHCL)
To evaluate the performance of the cognitive--linguistic skills of the students who participated in this research, it was used the Protocol of Assessment of Cognitive Linguistics Skills (PHCL) -collective version, Brazilian adaptation 24 .
The application of tests was performed in quiet rooms, under the direction of an applicator and supervision of other two applicators, following guidelines of the protocol itself.The test version used is composed of five parts: recognition of the alphabet in sequence, copy forms, writing under dictation, arithmetic and short-term memory.One point was scored for each correct answer on the test.
To facilitate statistical analysis the scores were divided into areas: -Alphabet: Table 2 presents a descriptive frequency distribution found in QARC according to the school grade and the total sample.
The comparative analysis between the scores obtained in the PHCL and the respiratory characteristics obtained by QACR was performed separately for each grade.Tables 3 and 4 show, respectively for 4 th and 3 rd grades, the comparison between the total score on PHCL and frequency of occurrence of each variable studied in QARC.In none of the variables questioned in QACR it was observed the p-value <0.01 when compared to the total score obtained by each grade.
In order to compare the prevalence of respiratory characteristics with the scores of the evaluated grades, there was the grouping of signs and symptoms reported in QACR, and for each sign/symptom present it is assigned a point.In this way it was possible to compare the scores obtained in QACR with the PHCL scores.Figure 2 shows the distribution of frequency of the scores on the questionnaire, by grade, and the minimum score obtained was zero and the maximum score 16 (21 questions).It was observed that 59.1% of the QARC had scores between zero and four points, indicating little impairment in respiratory variables studied.
Finally, Tables 5 and 6 show, respectively for 4 th and 3 rd grades, the comparison between the scores obtained in QACR and the scores obtained in PHCL.The analysis was performed taking into account the quartiles from the QACR scores and the searched areas.It was not obtained significant p value for the comparisons made in the studied grades.

DISCUSSION
Several authors emphasize the high prevalence of respiratory symptoms among children at school age, reaching values higher than 50% 25,26 .Respiratory disorders are common complaints from parents and teachers, who often describe allergy, flues and problems in the posture of the phonological articulators, such as the absence of labial sealing in their children and students.Oral breathing is the most common diagnosis when a series of these difficulties manifest together, which makes it the target of the development of various studies and researches 2-6, 8,9, 17, 22, 25,26 .
The learning process occurs gradually and in a complex way, and requiring skills from the phonological, syntactic and semantic components of the language 18 .Cognitive-linguistic skills such as memory, attention and concentration are also essential for the proper development of reading and writing 19 .Few protocols can currently provide the quantitative data regarding the assessment of these skills.Thus, for this research, we used a protocol published and studied in the Brazilian population 24 .Besides, this study went as far as to compare the students from the same public school in city of Belo Horizonte/Minas Gerais.
The average scores obtained in this study by applying the PHCL in areas such as the alphabet, copying figures and mathematics are consistent with those presented by a group of students of the same age and school grade of a school from the city of St. Paulo 27 .As to the areas concerning the word dictation, pseudo words dictation and digit memory in the present study they had lower average values than those reported by children from São Paulo.This difference can be explained by the population, as the survey which was conducted with students from the city of São Paulo excluded all children who presented changes in the otorhinolaryngological RESUMO Objetivo: relacionar características respiratórias com o desempenho em habilidades cognitivo-linguísticas de crianças de uma escola pública da grande Belo Horizonte.Método: estudo transversal, observacional e descritivo.Das 180 crianças recrutadas 131 atenderam aos critérios de inclusão e exclusão.Foram avaliadas 66 crianças da 4ª série e 65 da 3ª série do ensino fundamental, de ambos os gêneros, com idades entre nove e dez anos.Foi utilizado um questionário para investigação das características respiratórias e um protocolo previamente publicado e adaptado a população brasileira para avaliação das habilidades cognitivo-linguísticas.As informações coletadas foram analisadas por meio dos testes de Mann-Whitney e Kruskal Wallis, ao nível de significância de 1%.Resultados: não foi observado valor de p<0,01 na comparação entre as características respiratórias e as pontuações obtidas por cada série no teste das habilidades cognitivo-linguísticas.Observou-se que 59,1% dos alunos apresentaram escores no questionário de pesquisa das características respiratórias entre zero e quatro pontos, indicando pouco comprometimento respiratório.Conclusão: não foi encontrada relação significante entre o desempenho de habilidades cognitivo-linguísticas e a presença de características respiratórias em escolares de uma escola pública de Belo Horizonte, sendo que as crianças que apresentaram sinais e sintomas de alterações respiratórias não obtiveram desempenho abaixo daquelas sem estas alterações nas habilidades avaliadas.DESCRITORES: Aprendizagem; Escolaridade; Transtorno de Aprendizagem; Respiração Bucal

Figure 1 --
Figure 1 -Questionnaire administered to the parents of the children participating in the study

Table 1 -Descriptive statistics of scores according to the grade of study
-Copy: Copy figures (maximum score: 4) -Words dictation: Written words in Brazilian Portuguese (maximum score: 30) -Pseudowords dictation: Writing invented words (maximum score: 10) -Total dictation: Sum between the points obtained in the spelling of words and pseudowords (maximum score: 40) Legend: SD-standard deviation; Q1 -first quartile, Q3 -third quartile; ¹ Mann-Whitney non-parametric test.

Table 5 -Scores according to the quartile scores of the questionnaire for the 4 th grade
Legend: SD-standard deviation; Q1 -first quartile, Q3 -third quartile; ¹ Kruskal Wallis non-parametric test.

Table 6 -Scores according to the quartile scores of the questionnaire for the 3 rd grade
Legend: SD-standard deviation; Q1 -first quartile, Q3 -third quartile; ¹ Kruskal Wallis non-parametric test.