Movement cognition and narration of the emotions treatment versus standard speech therapy in the treatment of children with borderline intellectual functioning: a randomized controlled trial

The MCNT is an intervention in which children work in small groups, for 3 h each day, five days a week, Monday through Friday, for nine months. Each day they arrive at 2 pm, with a shuttle that brings them from their school to our Centre. They are divided into 3 groups, for the whole treatment, named Red, Blue and Green, according to their global functioning, grade and/or special educational needs. Upon arrival children are gathered all together for a 15 min long relaxing activity, after which each group starts with one of the three laboratories for 45 min. At the end of the first, the three groups switch the activity until all groups have completed all three laboratories.

MCNT is focused on the three domains affected in children with BIF that are strictly embedded with learning abilities: motor, cognitive and socio-emotional domain. This treatment consists of: a) Movement training to improve motor planning and fine and gross motor abilities with a Game Therapy approach using the Wii and Xbox video game platforms; b) Cognitive training for the empowerment of the executive functions such as working memory, planning abilities, problem solving, reasoning with the use of the multimedia interactive whiteboard (MIW); and c) an emotive training to learn how to Narrate the emotions to help the child to cope with the experiences of her/his daily life.

We chose to use the technology devices mentioned above because they are able to capture the attention and are highly motivating for the child. In addition, the use of the MIW represents a very useful visual aid for a visually-oriented teaching strategy that is effective in fostering verbal comprehension, memory encoding and storage processes. With both devices, moreover, it is possible to promote small competitions between the children which are very effective in motivating the child and improving information speed processing, positive interdependency and frustration tolerance. Finally, to help the child to narrate the emotions, a psychotherapist promotes several activities such as the narration of fairy tales, or drawing and symbolic playing to create a new story, to promote the capacity to think, to recognize and to master the emotions.

The first level concerned the movement execution and planning abilities: the objective is to improve balance, fine and gross motor abilities, hand-eye coordination, impulsive motor response inhibition, praxic abilities and attention. For this intervention, the Nintendo Wii Console with the “Wiimote” and the “balance board”, and the “Xbox 360 Kinetic” platforms were used. A game therapy approach is used to improve the children’s motivation and compliance. In the first weeks of treatment, the focus is on easier visual-motor integration skills, and the children familiarize themselves with the Wiimote while using it as a laser pointer to match a fixed visual input on the screen. A second step involves more complex games whereby the child points the Wiimote to a moving target (Wii Motion Plus game) that requires an increased involvement of attention and higher visual-motor integration ability. A third step involves games such as Wii Sports in which children use both the Wiimote and the Wii Balance board to train balance and coordination of both upper and lower limbs. Also, Wii Music and Wii Party games are used to train rhythm, timing of movement and inhibition of impulsive motor behavior. During the whole process, advanced executive functions, such as planning competence, working memory and inhibitory control are involved and trained so as to render the movements more fluid, economical, quicker and functional. Finally, the Xbox Kinetic console is used to train not only all body segments motricity but also moving in unison with another child. For example, in the Kinetic Adventure game, children maneuver a boat on river rapids in pairs with the movements of their bodies. In this step, the child needs to continuously adjust his/her own position in response to the movements of the other person. This activity facilitates training the awareness of his/her own body in space and relative to the other along with the capacity to master a novel situation in a cooperative manner.

The second domain concerns the cognitive abilities. The cognitive training is focused on several domains that include language comprehension and expression and executive functions, such as deductive and inductive reasoning, working memory, planning and problem solving, attention and concentration, inhibition of impulsive verbal responses. This part of the MCNT involves the use of the MIW. Particular attention is devoted to finding appropriate strategies to solve problems and to the constant training of the abilities to increase the velocity with which the task is executed. The aim is to promote the ability to explore the information, to select salient features which are relevant to solve the problem and finally to take a decision while examining the possible choices. Moreover, children are trained at keeping and sharing their attention with all members of the group for the whole duration of the session by promoting their active participation in the activities. Finally, according to the incremental intelligence theory [64], children are supported in the idea that their intelligence and their capacities can be increased by training and that each child has a different way to learn and to encode sensorial stimuli: some rely more upon visual strategies while others prefer verbal modalities. Indeed, great attention is devoted to the cognitive style and the learning strategies of each child. This approach helps the child to focus on the discovery of his/her personal functioning rather than being worried about the grade. Finally, working in a group promotes prosocial behavior and cooperative learning.

The third domain concerns emotions and social skills. BIF children very often lack adaptive skills and show behavioral, emotional and/or social-relations problems. The focus of this part of the treatment is to help the children to express, recognize and cope with their own emotions. We named this process “alphabetization” of the emotions [65]. The underlying idea stems from the psychoanalytic model of Bion [66, 67] in which the comprehension of the emotional experience is central to thought and learning. The term “alphabetization” refers to the capacity to transform the unknown sensations that precede and accompany any emotion into elements that can be thought and narrated [66, 67]. This process demands that the unknown sensations, which can generate discomfort, can be tolerated and contained in the mind of the subject and/or of the therapist for a sufficient time to be transformed into symbols that can be thought, experienced and communicated [65]. The alphabetization process operates through a symbolization mechanism that implies the “as if” process. Giving a simple name to the emotion is not sufficient, it is necessary to transform it into a metaphor, a story or a play. Such a process is very important for social relations: if the child can express his/her inner states, he/she has no need to act rashly upon them. Finally, the alphabetization process helps the child to “clear” the mind from very unwanted thoughts and sensations, which can ultimately facilitate the cognitive processes. The therapist, a psychologist with a psychotherapy degree, uses different approaches to promote the narration of the emotions: symbolic play, reading, inventing and/or dramatizing a story, drawing and talking. These activities are considered creative processes with a transitional function [68] that enable the children and the therapist to deal with the emotions in an indirect way, preventing the fear of being judged and persecutory feelings. Finally, such a transitional space enables and promotes the “as if” process [68]. The therapist helps the children to associate the feelings and emotions narrated and symbolized through the activities with their own experiences. Within the group, each child can introduce new characters, new scenarios and/or situations to challenge the group to find solutions. The goal is to encourage cooperation and to experience the facilitation effect of the group in thinking and coping with emotions.

STT is an individual treatment consisting of two 45 min sessions each per week for nine months. The focus is on the training of the academic abilities that are compromised in the child as assessed by the neuropsychological evaluation at T0 (pre-treatment). Typically, the skills mostly affected are reading comprehension, word-meaning relationship (semantics); writing problems related to phoneme-grapheme correspondence; arithmetic abilities; and problem solving. To empower these skills, SST uses both pencil/paper tools and specific rehabilitation software (http://​www.​erickson.​it/​). In the event of dyslexia or dysorthographia, the principal aims of SST are to increase processing information speed and transcoding, reducing spelling mistakes and expanding personal vocabulary. One of the approaches used is sub-lexical treatment. For dyscalculia, images are used to reason and solve the problem as, for example, in the analogical method [69]. Moreover, the empowerment of transversal competences such as phonological competences, perception, visual-spatial ability, attention, memory and other executive functions is pursued together with the use of compensative tools. Key criteria are functional re-education and the use of a meta-cognitive approach. The first provides for using alternative/different strategies to cover or partially rehabilitate compromised mechanisms whereas the second is based on strategies to focus the attention on mental processing (input, elaboration and output). Finally, the speech therapist offers pedagogy consultation for both parents and teachers to increase their knowledge concerning learning difficulties and potentially associated behavioral-emotional problems and finally to share effective problem solving strategies.

The timeline of the study is illustrated in Fig. 2. All children are evaluated at two time points, within two months prior to the beginning of the treatment (T0) and within two months after the end of the treatment (T1). For the no-treatment group the same time interval is kept.

To measure intellectual functioning and motor competences, we used the WISC-III [52, 53] and the Movement Assessment Battery for Children (M-ABC) [70], respectively.

The Emotional Quotient Inventory-Youth Version (EQ-i:YV) [71] was used to assess the emotion competences, while the Child Behavior Check List (CBCL 6–18) [61, 62] and Vineland 2 [63] were employed for investigating adaptive behavior.

A full neuropsychological evaluation was also made with the use of following tests: the Modified Bells Test (selective attention MBT) [56]; the Tower of London (TOL) planning ability and inhibitory control; [57, 58]; the Neuropsychological Evaluation Battery for developmental age 5–11 (BVN5–11, speech fluency, selective word retrieval and Corsi) [72] to assess verbal executive function and verbal and visual short term memory; the Test of Reception of Grammar-2 (TROG2, language comprehension) [59, 60].

Finally, our study includes measures of brain morphometry and function, evaluated by means of magnetic resonance imaging (MRI) as surrogate outcome measure. All children participating in the study are evaluated with non-conventional brain MRI to investigate brain morphometry and functionality in the regions that we found abnormally developed in our previous work [25]: the parahippocampal, temporal and sensory-motor cortices.

Primary and secondary outcome are evaluated at T0 and T1.

The primary outcome measures are:1 WISC-III; 2. M-ABC; 3. EQ-i:YV; 4. CBCL 6–18 and Vineland 2.

Secondary outcome measure are: 1. MBT; 2. TOL; 3. BVN5–11; 4. TROG2; and MRI.