Practical Methodology of Cognitive Tasks Within a Navigational Assessment

The aim of this video was to outline the methodology used to explore the cognitive factors that impact a child’s ability to navigate an SGD. Since the study by Robillard and colleagues¹ was the first of its kind with children, there was no pre-established protocol.

The decision to include children with typical development was made to obtain information on basic learning strategies and difficulties that relate to the use of this technology^18-20. The symbols were presented in a booklet (on one page) at the same time as the word for the symbol was said aloud to control for the participant’s ability to correspond the symbol to the referent and to ensure that only navigation was being measured. A pilot test determined that a 16-location grid was required. When more than 16 symbols per level were used, the complexity of the navigational task was greatly increased because of the need to scan more items per level to locate the symbols. Using less than 16 symbols per grid would have led to a greater need to change pages and may have increased the complexity of the navigational task. The number of words to identify for the navigational task (25) was also determined through pilot testing and was based on the number of items that the children could reasonably complete within a single session without needing a break.

SymbolStix²³ symbols were used because they came preloaded with Proloquo2Go²¹. Other types of symbols could also be used. The words selected were chosen from the younger stages of receptive vocabulary tests such as the Peabody Picture Vocabulary Test – Fourth Edition (PPVT-4)²² and the Échelle du vocabulaire en images Peabody (ÉVIP)²⁴. The words chosen were judged to be familiar for most children aged 4 to 6 years. The words chosen included concrete nouns that represented objects, animals or people. The order of presentation of the words was also determined through pilot testing. The words that had the highest success rate from the pilot group were placed at the beginning, while those with the lowest success rate were placed towards the end. Items were also placed in an order that would ensure that two successive symbols were not located under the same category. Some symbols could be found at the third level and others at the fourth level. Throughout the experimental navigational task, there was a progression in the level of difficulty. At first, the targeted words were under the same categories used in the practice portion. As the task progressed, new categories were introduced. In order to not discourage the participants, the most difficult words to retrieve were placed at the end of the task and were not administered to the children having reached a ceiling of eight consecutive errors, as this prompted the termination of the task. The participants were given a score of 0 for the items that were not administered.

As for the cognitive measures, the Leiter-R was selected because all subtests are non-verbal and could therefore be administered to children who have complex communication needs. Attention Sustained was selected to measure the ability to sustain attention. Picture Context was selected to measure categorization. Figure Ground was selected as a measure of cognitive flexibility. Sequential Order was selected to measure fluid reasoning. A new version of the Leiter-R³, the Leiter-3²⁵ would also be a good measure of cognition.

The results by Robillard and colleagues¹ showed that cognitive skills have an impact on the navigational skills of typically developing children who are new to AAC use. Sustained attention (Attention Sustained, Leiter-R), categorization (Picture Context and Classification, Leiter-R), fluid reasoning (Form Completion, Sequential Order and Repeated Patterns, Leiter-R), were all correlated with navigation¹. A more detailed discussion of the results can be found in Robillard and collaborators¹. Cognitive flexibility (Figure Ground, Leiter-R) was correlated with navigation in children and adolescents with a diagnosis of Autism Spectrum Disorder (ASD)², but was not correlated with navigation for young children with typical development. Among the factors correlated with navigation, the subsets that best predicted typically developing children’s navigational skills with a taxonomic organization included sustained attention, categorization, and fluid reasoning. Due to the small number of participants in the study on ASD, linear regressions were not possible. However, the correlation results open the possibility that cognitive flexibility could be an important factor for the prediction of navigational skills of children with ASD. New studies are needed with a larger number of participants. The speed of selecting symbols was not a variable in the previous studies, but could be added as a measure of processing speed.

Procedural limitations are present in this method. The administration of the assessment tools was carried out in multiple settings (i.e. private room, school with background noise, clinic). This could have impacted the participants’ performance. Visual acuity could have been assessed to rule out difficulties with vision. Some participants could have difficulty understanding the representations of the words even though symbols were presented in a booklet during the navigational task. The navigational task does not represent real communication and was in fact the first use of an AAC device after minimal training only. Navigational skills could be aided by personalizing the device, which could reduce the cognitive demands. This procedure was outlined for assessing children and was not examined for an adult population. Also, the validity of the cognitive factors could be questioned because they are difficult to isolate.

In order to reduce the limitations described above, all participants should be assessed in a private room with no distractions or background noise. When this is not possible, distractions should be limited in order to not impact the participants’ performance. When hearing and vision testing is not possible, difficulties could be ruled out by asking the participants’ families about hearing and vision acuity.

Other applications than Proloquo2Go^21,25 could be used. Other non-verbal cognitive tests could also be used to measure cognition, as long as they include numerous subtests that isolate the different cognitive components. Caution is needed when modifying the procedure outlined in this paper or when using alternative approached to assessing cognition, such as non-standardized cognitive tests, as the results could differ from the expected outcome.

It is important to understand how cognitive factors contribute to navigational abilities. The improper selection of an SGD could cause children and their caregivers to become frustrated and abandon the use of a device for communicative purposes. When choosing an SGD for young children, attention, categorization, and reasoning skills can be assessed to help predict their success with dynamic paging using a taxonomic organization¹. For children and adolescents with ASD, cognitive flexibility may offer the best prediction of navigational skills². More studies with other, larger clinical populations using the described method are required in order to determine the impact of cognition on navigation in children who require and use augmentative and alternative communication strategies.