Speech Therapy and Psychoanalysis: a case study with children with oral language delay

ABSTRACT

The present research aims to study the effects of interdisciplinary interventions of Speech Therapy and Psychoanalysis in children with language delay. This is a comparative case study between two groups with quantitative and qualitative analysis, with four children, through the application of the Protocol of Behavioral Observation Protocol pre and post intervention, interviews with parents, records of children's filming during playing and interdisciplinary dialogues among the professionals. The pre-intervention evaluations showed that underage children obtained similarity in aspects that related to communicative skills and functions, cognitive development and toy level. Both groups presented difficulties regarding the alternation of turns. The assessments of older children, in the pre-intervention phase, also indicated similarities in the results. One subject presented a greater difficulty when waiting for his turn in dialogic activity. The results post-interdisciplinary intervention showed a superior improvement compared to the two cases followed only by the speech therapist. The interdisciplinary dialogue made it possible to effectively evolve in the cases of group 2. A psychoanalytic look over the cases that received only speech therapy intervention would allow intervention along with parents, children and school.

Keywords:
Psychoanalysis; Speech Therapy; Interdisciplinary Research; Child Language

RESUMO

A presente pesquisa tem como objetivo estudar os efeitos das intervenções interdisciplinares da Fonoaudiologia e da Psicanálise com crianças com atraso na linguagem. Trata-se de um estudo de casos comparativo entre dois grupos com análise quantitativa e qualitativa, com quatro crianças, por meio da aplicação do Protocolo de Observação Comportamental pré e pós-intervenção, entrevistas com os pais, registros das filmagens das crianças durante o brincar e dos diálogos interdisciplinares entre as profissionais. As avaliações pré-intervenções mostraram que as crianças de menor idade obtiveram similaridade nos aspectos que se referiam às habilidades e funções comunicativas, desenvolvimento cognitivo e nível do brinquedo. Ambas as crianças apresentaram dificuldades quanto à alternância de turnos. As avaliações das crianças com idade mais elevada, na fase pré-intervenção, também indicaram semelhanças nos resultados. Um sujeito apresentou maior dificuldade quanto a aguardar o seu turno na atividade dialógica. Os resultados pós-intervenção interdisciplinar apresentaram uma melhora superior aos dois casos acompanhados somente pela fonoaudióloga. O diálogo interdisciplinar possibilitou a evolução de forma efetiva nos casos do grupo 2. Um olhar psicanalítico sobre os casos que receberam somente intervenção fonoaudiológica permitiria intervir junto aos pais, às crianças e à escola.

Descritores:
Psicanálise; Fonoaudiologia; Pesquisa Interdisciplinar; Linguagem Infantil

Introduction

Language acquisition occurs throughout the development of the child in a gradual way, considering the linguistic aspects of the community in which the child is inserted. A set of elements is part of the processes of the language development: neurological, physical, cognitive, behavioral, social and psychological ones^1-4.

Language development occurs from birth, but by the age of 2, the child starts to communicate more intelligibly with a still limited lexicon and forming telegraphic sentences. Before that age, the child uses the sounds of speech, gestures, looks, facial expressions to communicate with the world^5-8.

When the child does not develop as expected, it is said that he/she presents oral language alteration, which involves a set of heterogeneous classifications. One of them is language delay, which is characterized by a general delay in the acquisition and expression of all language components. When not only a chronological delay is perceived, but also a deviant construction of language, there are language disorders, which can be due to specific pathologies (hearing loss, autism, intellectual disability, neurological problems), or without an apparent cause. There is also speech sound disorder, which occurs when language development starts within the expected time, but with disorganization in the phonological component^6-12.

Specifically, in relation to language delay, the literature points out some risk factors related to this condition. On the one hand, neurological, biological and cognitive factors are cited that are linked to the pre, peri and postnatal period. Among these cases, prematurity, persistent otitis media, brain injury and intracranial hemorrhage are considered. These are conditions that contribute to cases of language delay, while influencing neuronal maturation and auditory development in the first few years of the child^9,10,12-14.

On the other hand, studies indicate that psychological, environmental, family and socioeconomic factors may also be associated with language delay. Some factors were emphasized in the studies such as: low parental education, low socioeconomic level of the family, precarious health conditions, lack of social/educational resources, mental health problems of the mother or caregiver, family conflicts (violence, abuse), little interaction with parents and lack of stimulation of the child^9,10,15-19.

Considering the demand for clinical treatment for language delays, this study proposes to analyze the effects of an interdisciplinary work between Psychoanalysis and Speech Therapy. The union between the inter and the disciplinary means what is common to two or more areas of knowledge^20,21. As a consequence, attention is paid to disciplines that share the same territory: language, speech, speech and listening²².

However, there is a conceptual difference regarding the term delay for the two areas - Psychoanalysis and Speech Therapy - with regard to speech and language. In the speech therapy field, speech delay is associated to a change in phonological development and the delay in language development, more global, related to language that does not occur within the chronologically expected age^7,9,11,12.

In Psychoanalysis, the delay in speech development would be related to a symptomatic condition of the subject and not a pathological one. Based on this evidence, it is considered important to state that the theoretical framework that will guide this research starts from the understanding that the subject is linked to a process of subjectivation where the symptom permeates a structuring path of psychic constitution.

In the specificity of the psychoanalytic reading, adopted in this study, the concept of subject includes a process of subjectivation of the child traversed in and by language. Thus, it is not possible to think of the process of language acquisition dissociated from this constitutive process. Then, the child constitutes his subjectivity based on family dynamics from which symptoms related to the delay in speech development can emerge, since the child refers to a place and a meaning in the parental discourse.

Stating the phenomenon of language as the central point of this study, it is sought, through both areas of knowledge, to clarify the changes observed in the process of language acquisition and its consequences, as well as the theoretical-practical interdisciplinary contributions to the effectiveness in the treatment of language delay, very common in speech therapy clinics.

It is in the dialogue between Psychoanalysis and Speech Therapy that language development, typical or delayed, can be a promising bet. Early intervention in cases of language delays, considering that prevention or anticipation is determined by the notion of time, could prevent the onset of a language symptom or the aggravation of developmental problems^23-25.

Thus, this study aims to investigate the effects of interdisciplinary interventions of Speech Therapy and Psychoanalysis in children presented with language delay.

Presentation of Cases

This research was properly registered and approved by the Ethics Committee in Research with Human Beings of Universidade Federal de Santa Maria, Brazil, under the registration number 4,334,964. This is a case study and it was carried out by signing the Free and Informed Consent Form (ICF) by the parents of the children. The children also agreed to the survey through the Term of Assent.

The sample consisted of four male children, with oral language delay, aged between 2.0 and 4.11 years, selected from the waiting list of the Speech Therapy Service (SAF) of the Higher Education Institution (HEI) in which the research was carried out.

Children who presented hearing disorders or who were experiencing middle ear infection (otitis) were excluded from this research; neurological changes; intellectual disability associated or not with syndromes; exclusive phonological disorder and children who had already undergone speech therapy. The inclusion criteria for the parents of the children were: acceptance to participate in the study; having children diagnosed with oral language delay; being monolingual in Brazilian Portuguese and be legally responsible for their children.

For the selection of research subjects, initially, the welcoming reports of ten patients awaiting care in the language sector of the SAF, between April and May 2021, were analyzed. The reports contained identification data, contact, initial interview, evaluation procedures, diagnostic impression and conduct, which allowed accessing information about the child's history, general and hearing health.

It should be noted that, despite considering the age of 2 years as the minimum age and the age mark for the diagnosis of oral language disorders, two children were included in the study at a younger age. We chose to include them, as they were close to 2 years of age and had developmental characteristics compatible with oral language delay.

All children were submitted to anamnesis, interview, Orofacial Myofunctional Assessment with Scores (OMES)²⁶, auditory evaluation and assessed by a speech therapy instrument named Behavioral Observation Protocol (BOP)²⁷. In this sample selection phase, BOP was used for diagnosis, in order to confirm the diagnostic impression of language delay. This instrument also made possible a comparative analysis, through reapplication after the intervention. It should be noted that the anamnesis, language assessments, orofacial motricity and hearing screening were performed by a speech therapist with experience in the language area, who voluntarily participated in the research.

After the completion of the described evaluations, a number of four subjects was obtained and a raffle was carried out to elect two subjects for each group. The subjects were assigned to the therapy groups, called Group 1 (G1) - composed of two children who received only speech therapy; and Group 2 (G2) - composed of two children who received speech therapy and psychological intervention, focusing on interdisciplinary interventions.

In relation to the data collection procedures, the following instruments and procedures were used:

• BOP, applied by the speech therapist in order to compare the results of the evaluation of each participant before and after the intervention;

• Psychoanalytic analysis, performed by the psychologist, the first author of this study, in order to assess the association of children's symptomatic issues with speech development delay (language delay for the Speech Therapy);

• Sessions with parents were also carried out by the psychologist in order to understand family dynamics and the place of children in parental discourse.

Meetings with the children were held weekly for a period of three months. In G1, there were 12 speech therapy sessions with each child and, in G2, 12 speech therapy sessions and 12 psychotherapy sessions. The children were filmed during the moments of interaction with the professionals.

With the children from G1, the speech therapist performed the therapy as she had traditionally been working since her formation and according to the theoretical line of cognitivist baseline. In G2, the professionals previously defined aims and strategies necessary for the work, as recommended by interdisciplinary work. In G2, the sessions with the speech therapist started and, afterwards, the sessions with the psychologist were held. All sessions lasted approximately 50 minutes each.

The follow-up with the parents was carried out fortnightly and the sessions were audio recorded. At the end of the work, feedback was made with the parents of the children, as well as the necessary referrals.

The interdisciplinary dialogue between the speech therapist and the psychologist took place every week, in order to discuss questions about speech and language presented during the sessions with the children of G2.

The analysis of the results was developed from the transcripts of the videos filmed during the sessions, whose data were later analyzed through clinical clippings of the cases and interventions based on the support for the psychoanalytic theory. The transcription of the recordings of the interviews with the parents also allowed information about the child past history to be included in the analysis of the study.

Furthermore, the exchanges in the interventions carried out between the speech therapist and the psychologist were included for analysis. Additionally, the data obtained through BOP were computed, according to the indications contained in the protocol, in order to observe the evolution in language and in symbolic play.

Results

To present the results of this study, the children from G1 (speech therapy intervention) will be named Bento and Wagner, and those from G2 (interdisciplinary intervention), Gabriel and Lúcio.

Chart 1 presents the results of BOP carried out before and after the intervention of the four subjects, followed by a description of the results of the interventions in each case. Next, the analysis of the clinical cases will be explained.

Chart 1
Results of the pre and post-intervention Behavioral Observation Protocol

Observed Aspects
Patients	Communicative skills (60 points)		Verbal language comprehension (40 points)		Aspects of cognitive development (50 points)		Total (150 points)
	Pre	Post	Pre	Post	Pre	Post	Pre	Post
Bento (ST)	19	28	20	20	03	02	42	50
Wagner (ST)	46	60	25	25	31	44	102	129
Gabriel (ST + PT)	25	41	35	40	03	41	63	122
Lúcio (ST + PT)	37	58	25	40	30	43	92	141

• Captions: ST - Speech Therapy. PT - Psychological Therapy. Source: Authors

The case of Bento (G1)

Bento started therapy when he was 1 year and 11 months old. The pregnancy was not planned. It was a twin pregnancy, bivitelline. The babies were born premature, by cesarean section, at 7 months. Bento was born weighing 1,550 g and spent 1 month in the Intensive Care Center (ICU). His brother was stillborn, weighing 700 g. According to the report of his father, Bento ate more than his brother, who did not gain enough weight to develop.

As for language development, Bento uttered his first words at 1 year of age and, at 1 year and 7 months, he spoke around fifteen words. Regarding neuropsychomotor development, he crawled (quadruped) by the age of 1 year and 7 months and he walked by the age of 1 year and 10 months. Due to prematurity, since the age of 4 months, he has been followed up weekly with an occupational therapist and every three months with a pediatric follow-up.

Regarding the pathophysiological antecedents, the father reported that the son of a cousin of his, 4 years ago, was diagnosed with autism and that he was worried about his son becoming autistic, because he presented some repetitive behaviors, such as, for example, putting hands on head and scream.

Regarding the results of BOP, it was found, in the pre-intervention assessment, in the communicative skills category, that Bento presented some difficulties in interaction, in communicative intention, in the alternation of turns, with absence in several aspects in the communicative functions. He presented intentional communication with primary functions and restricted participation in dialogic activity by non-verbal means. In the category levels of language contextualization, it was observed that language referred only to the immediate and concrete situation, comprising orders only with an action. Regarding aspects of cognitive development, it was noticed that Bento explored the objects through few actions, manipulating them without an organization, not presenting symbolic behaviors, only sensorimotor.

In the pre-intervention period, Bento presented a restricted vocabulary, which was not expected for his age. The syntax was structured with few word productions, in an isolated way, and, in most cases, non-verbal communication was used, such as pointing to request orders and objects.

Speech therapy was based on the stimulation of expressive and comprehensive oral language. The sessions were carried out in a playful way, with the objective of expanding the lexicon, encouraging the construction of simple sentences, developing communicative intention, taking turns, communicative functions and improving symbolic play, which was under construction during the therapeutic process.

Throughout the therapeutic process, Bento turned to the speech therapist more often, asking for objects verbally, using isolated words. The parents were guided by the therapist to dialogue more with the child and assign meaning to their words and actions.

After the 12 sessions, it was verified that Bento started to show interaction and communicative intention, but he still presented some difficulties in relation to the shifts and their alternation. He showed improvement in some aspects of communicative functions, since, through gestures (pointing, nodding, come-here gesture), he requested objects, asked for permission, interrupted an unwanted action, started and ended the interaction. He produced inarticulate vocalizations, but it was noted that he was in a process of verbal construction of oral language development.

In the category levels of contextualization of language, it was observed that language referred only to the immediate and concrete situation and, in the category of verbal comprehension, it executed orders with only one action. Regarding aspects of cognitive development, it was noticed that Bento explored objects with a short attention span, quickly and superficially and through few actions. He still presented sensorimotor behaviors, despite already being in the process of transitioning to symbolic behaviors.

In relation to the toy level, he organized the miniatures into small groups, reproducing partial situations, but without an organization of the whole set, indicating difficulties regarding the evolution in the aspects of playing. Improvement was noticed in issues related to the patient's language, but still in delay, not meeting the expected age. Bento produced isolated words in greater quantity, demonstrating the expansion of vocabulary and production of small telegraphic phrases, such as “me dá”. In addition, an improvement in the organization of play was observed.

The case of Wagner (G1)

Wagner was 04 years and 09 months old at the beginning of the research. His mother brought the speech delay complaint evidenced by the teacher of the preschool he had been attending since 1 year and 5 months, and later confirmed by the pediatrician. As for the gestational period, the pregnancy was not planned and the father did not react well to the news. The delivery was normal, at 38 weeks and Wagner weighed 3.2 kg, measuring 47 cm, and there were no complications during this period.

Regarding breastfeeding, due to cracks in the breast, the mother breastfed for a short time. Wagner was using a bottle at the time of the interview. He used a pacifier most of the day and during the night. He shared a room with his mother and younger sister, as there was no physical space in the house for him to have a single room.

In relation to the language development, according to his mother, Wagner spoke few words, did not form whole sentences. At 2 years and 6 months old, he only spoke the word “mamãe”. He started producing words at around 4 years and 4 months and used gestures to communicate.

Regarding neuropsychomotor development, Wagner crawled before 1 year of age and started walking at 1 year and 3 months. About educational development, Wagner attended a special class at the school, because, according to his mother, he did not accompany the group of “normal” students and did not like to do the activities. Concerning the pathophysiological background, his mother has aunts and cousins with speech difficulties.

The parents had been separated for 4 years and Wagner had little contact with his father. Wagner had a younger sister (3 years old) and an older sister (9 years old). When asked his age, Wagner said he was 3 years old, just like his younger sister.

In relation to the results of BOP regarding the speech therapy pre-intervention, in the communicative skills category, Wagner demonstrated interaction and communicative intention with the professional. It was noticed that the child was waiting for his turn, actively participating in the dialogic activity and producing telegraphic sentences with three or more words from different categories. In the verbal comprehension category, he only understood orders with up to two actions. In the category levels of language contextualization, she described the action being carried out making references to the past and the immediate future, without going beyond the immediate context. Regarding aspects of cognitive development, it was verified the exploration of objects one by one in a diversified way, making conventional use of them and dolls in symbolic toy. In addition, he created symbols with substitutive objects and made use of verbal language to report what was happening in the play situation. Furthermore, in the toy level category, Wagner organized the objects distributing them in order to configure the different rooms of the house, grouping the objects in defined categories, forming classes. In the pre-intervention period, it was observed that Wagner, despite having a wide vocabulary, presented a gap in the levels related to syntax, pragmatics and phonology. He used to create storytelling, rich in detail, but unintelligible and disorganized for his age.

Speech therapy was based on the stimulation of expressive and comprehensive oral language at all levels, as well as on the interaction and organization of symbolic play. During the therapeutic process, there was an evolution of the aspects worked by the speech therapist. The mother also reported that her son was more talkative and showed greater interest in school activities. It is noteworthy that, at the end of the interventions, he reached the maximum score in communicative skills. He showed interaction and communicative intention with the speech therapist, respected shift alternations and actively participated in the dialogic activity. He showed increased vocabulary, discursive ability with experiences that went beyond the immediate context, evoking past situations and anticipating future situations. However, there was some level of difficulty in understanding orders with more than two actions, in the verbal comprehension category, keeping the score obtained in the pre-intervention phase.

Regarding the aspects of cognitive development, Wagner acted on two or more objects at the same time, relating them in a diversified way, persisting when there was an obstacle, trying to overcome it, using dolls in the symbolic toy, organizing symbolic actions in a sequence, creating symbols, making use of substitute objects/symbolic gestures to represent absent objects and made use of verbal language to report what was happening in the toy situation. In the toy level category, the child showed an evolution in terms of organization in their play, distributing the objects in order to configure the different rooms in the house, grouping them into defined categories, forming classes and ranking them according to differences.

After speech therapy intervention, an evolution was observed in aspects related to oral language, as well as its interaction and organization of play - centered on the body itself and also using make-believe. There was an increase/expansion of vocabulary (lexicon), improvement in aspects related to sentence construction, being possible to organize sentences with more than three elements (complex), for example, and in a more organized way. He also made short reports/stories using a broader and imaginative vocabulary. It presented evolution in syntactic, semantic and pragmatic issues, but still presenting difficulties related to phonology (and phonetics).

The case of Gabriel (G2)

Gabriel started the research at 01 year and 08 months. His parents had been in a relationship for 10 years. They brought the complaint that he spoke few words and used onomatopoeia, in addition to many gestures to communicate. As for the gestational period, the pregnancy was discovered in the 6th month. Regarding the delivery, it was a cesarean section and the maternal grandmother was accompanying her. The mother was unable to breastfeed the child and, for that, a professional speech therapist tried to help in the hospital, but without success. Gabriel used a bottle until the time of the research.

In terms of neuropsychomotor development, Gabriel crawled backwards at about 1 year and 2 months and then started walking. During the day, Gabriel stayed with his maternal grandmother and played a lot. In relation to the pathophysiological background, he has an autistic cousin, a schizophrenic uncle and a great-grandmother who had Alzheimer's.

Regarding the results of the pre-intervention BOP, it was observed that, in the communicative skills category, he demonstrated interaction and communicative intention, but presented difficulties regarding the alternation of turns, with the absence of several communicative functions. Intentional communication with primary functions and restricted participation in dialogic activity by non-verbal means were observed (he made non-articulated vocalizations, pointed and made a come-here gesture). In the verbal comprehension category, he understood order with only one action.

In the category levels of language contextualization, it was noted that language referred only to the immediate and concrete situation. Regarding aspects of cognitive development, a short attention time was noticed, exploring objects quickly and superficially, presenting a sensorimotor behavior. In relation to the toy level, he organized miniatures in small groups, reproducing partial situations, without organizing the whole set.

During the psychological interview with the parents, the mother reported her desire to become pregnant again, contrary to the father. The father did not attend the birth because he was afraid of fainting and said he was afraid of seeing blood, which made the mother feel sad. The boy slept with his parents until the 6th month. Due to the growth Gabriel and the discomfort of sharing the bed, the father started to sleep in the living room and the child remained sleeping with the mother in the bedroom.

The mother supposes that her absence due to work may have generated the symptoms in the child. The father, on the other hand, says that, since the birth of the child, the marital relationship has been affected with a lack of dialogue, which makes a separation possible.

In his first session with the psychologist, Gabriel barely explored the room, barely making any sound or words. Thus, the psychologist named the objects according to his interest. Later, he actively sought out the naming of the psychologist, reaching for boxes of toys and asking what they were. During the sessions, it was observed that Gabriel increased his vocalizations and produced isolated words, such as “nenê”, “papai” and “mamãe”, expanding his vocabulary/lexicon. In the interdisciplinary dialogue, the professionals shared impressions about the evolution of expressive language, the organization of playing and the increase in the production of onomatopoeia.

In one of the sessions with the psychologist, it was noticed the interest of the boy in having his father together in the room. It was also noticed that Gabriel is excited by the presence of his father and addresses the toys in the box to him. He takes the motorcycle and says “bãbá” and the psychologist asks: “how does the father do with this motorcycle?”. The father goes “vrumm vrumm vrumm”, reporting that Gabriel has been talking and vocalizing more. The father says that, at home, he is the one who fixes things that break, and that, when he does the maintenance of his motorcycle, Gabriel follows through, going through the toolbox. The psychologist points out that Gabriel also shows interest in fixing toys in the sessions. Throughout the sessions, Gabriel continues to try to fix the toys, asking for help to find the tools, keys and words that can shape his experiences in the midst of the parental plot.

In the session with the mother, she reports the evolution of Gabriel in words and informs that she is explaining more situations to the boy, such as, for example, that he will enter the session and she will be waiting in the waiting room. In addition, she mentions that she has been talking more with the father of Gabriel.

In the interdisciplinary exchanges, it was paid attention to the interpretations of the staging in the playing of Gabriel during the sessions. Initially, he played with the therapeutic family, putting the baby in the same bed with the parents, but, in the course, he put the baby in a bed alone, appropriating the desire to sleep alone. For the speech therapist, the questions raised by the psychologist regarding the parental dynamics imbricated in the symptoms of Gabriel started to make sense, looking back at the constitutive aspects, which she reflects in a different way in her practice. With this, the more rigidly pre-determined clinical practices for the speech therapy sessions are being deconstructed, allowing the child to explore what really interests him. It is noted that there is a clinical redirection and the expansion of the perception about playing with a view to developing a listening in relation to the subjectivity of the child. Theoretical-practical knowledge of the language and speech aspects shared by the speech therapist produces a difference in the understanding of development, influencing the work of the psychologist in the case.

Regarding the results of BOP after the intervention, there was an improvement in communicative skills of Gabriel. He demonstrated interaction and communicative intention with the therapist, through expressions and symbolic gestures, he requested objects, asked for permission, interrupted unwanted action, started and ended the interaction. However, sometimes he would rush into his shift, interrupting the therapist. Even though the child was not using the oral language resource, he managed to advance through more articulated vocalizations with language intonation. As for the aspects of verbal comprehension, Gabriel showed improvement in the execution of orders, going from one to two actions.

In the category levels of contextualization of language, he presented some evolution, since he described the action that was being carried out, making references to the past and/or immediate future, without going beyond the immediate context. It also showed evolution in aspects of cognitive development. He acted on two or more objects at the same time, relating them in a diversified way, persisting when there was an obstacle, trying to overcome it, using dolls in the symbolic toy, organizing symbolic actions in a sequence, creating symbols and making use of substitute objects/symbolic gestures to represent missing objects. In relation to the toy level, Gabriel presented some significant progress in organizing his play, distributing the objects in order to configure the different rooms in the house, grouping them into defined categories, forming classes and ranking them according to differences.

Thus, as the interventions with Gabriel and his parents took place, together with the interdisciplinary work, a significant improvement was noticed in the development of the child (organization of playing, increase in vocalizations, production of words and onomatopoeias and expansion of resources symbols) and reorganization of family dynamics, which led Gabriel to express a desire to sleep alone in his room, redirecting questions to the parental couple.

The case of Lúcio (G2)

Lúcio started the research at the age of 4 years and 5 months. When he was 2 years old, the preschool teacher requested speech therapy because he did not talk much at school and could not express himself. In an interview, the parents reported that the pregnancy was planned and went smoothly. Lúcio was breastfed until his 5th month, he used a bottle and did not use a pacifier. The unfurl occurred at 3 years of age. Regarding neuropsychomotor development, Lúcio crawled at 8/9 months and walked at 1 year and 4 months. As for language development, he didn't babble much, he was quieter. At age 2 he started to speak his first words, but he spoke more at home than at school.

Lúcio is an only child and his parents say they are overprotective. He has his own room, which he has slept in since he was 2 years old. The father complains that Lúcio finds it difficult to play with his cousin and other children without fighting and that he does not accept sharing the toys. He would very much like his son to improve his interaction with the children.

Regarding the results of the pre-intervention BOP, in the communicative skills category, it can be seen that Lúcio showed interaction and communicative intention with the speech therapist, but he had difficulties in waiting for his turn and alternating in the dialogic activity.

It was observed that the child emitted telegraphic sentences with three or more words from different categories. In relation to the levels of contextualization of language, he referred only to the immediate and concrete situation. In the verbal comprehension category, it comprised orders with up to two actions. Regarding aspects of cognitive development, he explored objects one by one in a diversified way, making conventional use of objects, using dolls in the symbolic toy, organizing symbolic actions in a sequence and making use of verbal language to report what was happening in the situation. toy. And, for the toy level, Lúcio lined up the objects, making small groups of two or three objects, organizing the miniatures in small groups, reproducing partial situations, distributing the objects in order to configure the different rooms of the house, but without an organization at all the set.

While Lúcio was in his first session with the speech therapist, the psychologist was having a session with the parents. During the session with his parents, Lúcio knocked on the door and entered the room in tears, being welcomed by his mother. The parents tried to calm him down and the father told the son that he did not need to cry. The speech therapist invited Lúcio to return to the session, but he objected. Then the psychologist suggested that the mother would play with him.

This initial scene represents the first exchange between the professionals, in which the psychologist authorizes the speech therapist to participate in the maternal session with the child. In a dialogue after the fact, the speech therapist reports to the psychologist that she felt a lot of anxiety/anguish in the session, due to the agitation of the boy. She says that she tried an initial activity with the boy, who also seemed anxious, but that he was not interested. She says that he switched between toys a lot, made a mess, unable to keep his attention in any game. With his mother present at the session, Lúcio calmed down and was able to play. In turn, the mother remained seated, silent, without interaction and position in face of the attitudes of the child.

Lúcio had an almost unintelligible, infantilized speech, without pauses, without stopping, with changes in speech. Sometimes he spoke in 3rd person, when referring to himself, like: “L. does not like", "L. fell out". He also called himself “baby” in front of his father, which he exemplified: “baby does not want to”.

In the first sessions Lúcio manifested anxiety, exploring toys very quickly and without organization with play. In the course, he became interested in swords and summoned the psychologist to fight with him. During the fight there was a need to establish some limits so the two would not get hurt and the psychologist has the use of shields to protect themselves in some moments of the battle. In one session, he calls his father into the waiting room and hands him swords to fight, in which the interaction with the father is observed.

Over time, in the sessions with the psychologist, the evolution of Lúcio in relation to limits, creativity, and organization in playing was notable. He waits his turn in the game and manifests himself more in first person, as in the following examples, referring to a fruit domino game: “I got a cashew pepei (red)”. These aspects were also presented in the sessions with the speech therapist, who added that she also observed evolution in aspects related to oral language, such as vocabulary expansion, more elaborate phrasal constructions, with more than three elements and in a more organized way. As a result, there is growth in the syntactic, semantic/vocabulary and pragmatic components.

It was possible to observe these aspects in the reapplication of BOP. In the communicative skills category, Lúcio demonstrated interaction and communicative intention, with a significant improvement in waiting for his turn and alternating it, actively participating in the dialogic activity. It was noted that Lúcio improved his vocabulary, describing experiences with 5/6 word sentences. In the category levels of language contextualization, it also presented evolution, going beyond the immediate situation, referring to events more distant in time (evoking past situations and anticipating future situations), comprising orders with three or more actions, making requests and comments that referred to absent objects, people or situations.

In relation to the aspects of cognitive development, Lúcio acted on two or more objects at the same time, relating them in a diversified way, persisting and trying to overcome obstacles. He used puppets in symbolic play, arranging symbolic actions in a sequence, creating symbols, making use of substitute objects/symbolic gestures to represent absent objects, and making use of verbal language to report what was happening in the toy situation. Thus, in the “level of play” category, Lúcio presented some progress regarding the organization of his play, distributing the objects in order to configure the different rooms of the house, grouping them into defined categories, forming classes and ranking them according to the differences.

Parents report noticing the difference in their child throughout the interventions. The father became firmer with the boy, setting limits. Lúcio talks more, plays without fighting, is interested in games and takes care of his toys more. However, he still presents some difficulties related to phonology.

Discussion

The assessment using BOP signaled more robust differences in patients who received interdisciplinary intervention, in terms of language levels, communicative functions, verbal comprehension and aspects of cognitive development, being visible mainly in the total score. The discussion that follows will be between Bento and Gabriel cases; and between Wagner and Lúcio, due to the proximity of their age and for receiving different therapies.

The similarities in the results of the pre-intervention BOP of Bento and Gabriel were: difficulties in alternating shifts; absence in various aspects of communicative functions; intentional communication with primary functions; restricted participation in dialogic activity and by non-verbal means; language referring only to the immediate and concrete situation and verbal understanding of orders with only one action. The differences were that Gabriel showed interaction and communicative intention, aspects not observed in Bento. In addition, even though in relation to playing the objects were explored in a superficial way and with few actions in both, Gabriel organized the miniatures in small groups, reproducing partial situations, while Bento just manipulated the objects without any organization. This variation of linguistic manifestations is traditionally reported in the literature, indicating a good therapeutic prognosis^28,29.

Still, contrary to what was observed in relation to the play development of Bento, Gabriel made some progress regarding the organization of his play, distributing the objects in order to configure the different rooms of the house, grouping them into defined categories, forming classes and serializing them according to the differences. In relation to the execution of orders, in the verbal comprehension category, Gabriel went from one to two actions, showing an evolution in the language aspect. He described the action being taken, making references to the immediate past and/or future, without going beyond the immediate context. Opposite to what the results of the work with Bento show, Gabriel also shows improvement regarding the shift and alternation, advancing in vocalizations (more articulated with the intonation of the language). For Ferreira³⁰, once assuming the position in the dialogic exchange (turn-talking), there is the support of an alterity.

Regarding the life history, the parents of Bento bring the assumption that Bento deprived them of their other child, a stillborn twin brother. Parents showed difficulties talking about the loss of the other child, even moving house after the event. In addition, they were concerned that their child might be autist. In association, it is pointed out in the literature that depression due to the loss of children is described as a risk factor for autism. The lack of the mother in relation to libidinal investment, in her depressive condition, has consequences in the process of the drive circuit, as there is a lack of erogenous elements for the constitution of the mother-baby bond. These conditions can generate symptomatic contact avoidance reactions, which can be confused with autistic symptoms in babies. Consequently, there is some difficulty in the process of alienation necessary for the psychic constitution²³.

It is observed that, in the Bento case, the results of the assessments did not indicate behaviors that referred to autism spectrum disorder (ASD). However, it is possible to bet on the hypothesis of a depressive parental position, based on the issue of unprepared grief in relation to the loss of the child, a condition that made the development process of Bento more difficult. In addition, the need for parents to be present for Bento during the speech therapy sessions was observed. When he was going to be left with the professional in the room, Bento would cry and look for his parents. With this, it is understood that the work with Bento permeates listening to the parents. In Psychoanalysis with children, even though they are the subject in question, it is necessary to look at the said and unsaid of the parents.

For Costa³¹, listening to them is part of managing the transference, a central element in supporting the analysis of the child. Therefore, it is a matter of listening to where the child is situated in the desire of the parents, in the discourse they maintain about them and in the parental phantasmagoria. According to Mannoni³², the discourse that is processed analytically around the symptom presented by the child is collective, as it includes the parents, the child and the analyst. A psychoanalytic perspective would allow intervening with the parents of Bento, listening to their phantasmagorical discourse and working on issues related to loss.

Regarding his symptoms, it is observed that, after the intervention with the speech therapist, Bento made some progress. There was an improvement in the aspects of interaction and communicative intention and their functions, since, through gestures, they requested objects, asked for permission, interrupted an unwanted action, started and ended the interaction. On the other hand, he presented difficulties in relation to the shifts and the alternation of these after the interventions. Ferreira³³ points out that the dialogic exchange (turn-talking) between the mother and the baby/speaker and listener is configured by a speech of enunciations, composed by the alternation of speech turns. Pereira, Vorcaro and Keske-Soares³⁴ point out that it is essential the rhythmic alternation of presence and absence, since it is in the interval that the assumption of the mother about the desire of the child shows up.

Bento also remained with a language that was intended only for the immediate and concrete situation, executing orders with an action, exploring objects with a short attention span, quickly and superficially and through few actions, with difficulties related to playing, even presenting sensorimotor behaviors. However, according to the speech assessment, Bento was in the process of transitioning to symbolic behaviors, signaled through the behavior of repetition. Thus, despite the improvement in issues related to his language, he still lagged behind. As pointed out in the literature in the area and the therapy time markers suggested by the Conselho Federal de Fonoaudiologia (Speech Therapy Federal Council), it is understood that, in a few months of treatment, improvements are already noticeable in children with language delays, and the prognosis of discharge is estimated around 1 year or more of treatment^28,29,35.

It is possible to verify significant differences in relation to the assessments and interventions in the Gabriel case. Like Bento, Gabriel improved in aspects of communicative functions (requested objects, asked permission, interrupted an unwanted action, started and ended the interaction). These functions described by BOP, a speech therapy instrument, are seen happening in the work of the psychologist with Gabriel already in his first session, when he starts to name objects according to his interest. Through gestures, he pointed, requested and expressed curiosity about the toys, picking them up while the psychologist named them.

The naming offered by the psychologist allowed access to the symbolic field. In this field, there is a “system of representations in which words name objects, people, phenomena”²⁴. The addressing function is observed when Gabriel requests the naming of the psychologist, denoting his insertion in the universe of language, permeated by the field of the Other - also provider of the first signifiers. Based on that assumption, Lacan³⁶ states that “these signifiers organize human relationships in an inaugural way, give them their structures, and shape them”.

Then, in relation to the psychoanalytic field, language precedes speech and is a condition of the subject articulated to a symbolic significant plot³⁷, so that the delay in speech development is not related to a pathological condition, but to the symptom, a production of the subject. Differently, in the speech area, in a broad way, the delay in language development concerns the language that does not happen within the chronologically expected age and the speech delay is related to a change in phonological development^7,9,11,12.

The interdisciplinary work allows us to establish that the symptomatic issue refers to the parental discourse. Regarding the speech presented by Gabriel, it is interesting to observe that the mother supposes that her absence due to work may have generated this delay symptom in her child. In this sense, she points out that sleeping with her son would be a moment to spend more time with him, added to the fact that the mother is silent in the face of the question of the psychologist about the construction of the room of Gabriel. It gives the impression that, during sleep, the maternal lack can be supplied, but, at the same time, it is interesting to observe that there would be a presence without speech (since they are sleeping). In this sense, there is an absence in terms of speech.

Another element that appeared for analysis in the Gabriel case was the constant presence in the maternal discourse about the lack of the father. The mother reports the absence of the father during childbirth, when he is away from the room of the couple, among others. Note that, during the sessions, the father is present and participatory. In this sense, the psychoanalytic reading of the parental discourse made it possible to broaden listening to the questions that emerged during the sessions. Thus, the advances in the different aspects of the development of Gabriel were a consequence of the intervention between the professionals, which denotes the role of interdisciplinarity in relation to the case.

Regarding the cases of Wagner and Lúcio, it was noticed, through the results of the pre-intervention BOP, a similarity in the communicative skills category, in the item interaction and communicative intention. Both children also presented telegraphic sentences with three or more words from different categories and, in the verbal comprehension category, they understood orders with up to two actions. There was similarity between the children in the aspects of cognitive development and in relation to the level of the toy, since both explored the objects one by one in a diversified way, making conventional use of objects, using dolls in the symbolic toy and making use of verbal language to report what was happening in the play situation.

On the other hand, only Lúcio presented difficulties in the alternation of shifts and, at the levels of contextualization of the language, he referred only to the immediate and concrete situation, while Wagner described the action and made references to the past and the immediate future, even without going beyond the immediate context. It was also observed that Wagner presented an expressive vocabulary, constructed sentences, understood, named and symbolized, but had speech changes and phonological issues, with very infantilized speech, according to the speech therapist.

It is noted that the transferential relationship established with the professional allowed the bet on the development of the boy and, as a consequence, led Wagner to show interest in words.

It is verified that Wagner was enrolled in a special class because, according to his mother, he did not follow the “normal” class and did not like to do the activities of the “normal” classes. The actions taken in the speech therapy work presume that the dialogue with the school could allow Wagner to return to his previous (“normal”) class. Apparently, now there would be more desire to learn. The psychoanalytic work would contribute to the communication with the school and to the listening to the parental discourse, with the attempt that there could be an understanding between the parents to deal with the issues of the child, a constant complaint of the mother in relation to the father.

Wagner also told the speech therapist that the parents fought a lot and the follow-up with the psychologist would make it possible to give the questions of Wagner a place to listen. A recent study reveals positive effects of psychological work on speech therapy, signaling the importance of an interdisciplinary relationship with regard to analysis, assessment, detection and intervention in subjects with language disorders³⁸.

The reapplication of BOP showed that Wagner evolved in linguistic aspects (expansion of vocabulary and reports on experiences outside the context of therapy) and in the organization of play. However, he did not advance in the verbal comprehension category, indicating difficulty in understanding orders with more than two actions. Wagner showed progress in syntactic, semantic and pragmatic issues, but still had difficulties in relation to phonetics and phonology. Since the difficulties presented at the end of the research focused strictly on phonological issues, he was referred for speech therapy in the speech department.

Different from Wagner, Lúcio received an interdisciplinary intervention and, in the reassessment of BOP, he showed a significant improvement in terms of waiting for his shift and alternating it. Like Wagner, he also showed improvement in vocabulary, but sometimes he still emitted telegraphic sentences with three or more words from different categories. Lúcio evolved like Wagner in the contextualization of language, going beyond the immediate situation, evoking past situations and anticipating future situations. In relation to verbal comprehension, Lúcio surpassed Wagner, as he understood orders with three or more actions, making requests and comments that referred to absent objects, people or situations. He also made progress in organizing his play, distributing objects in order to configure the different rooms in the house, grouping them into defined categories, forming classes and ranking them according to differences.

It could be affirmed that the evolution of Lúcio might be related to the interdisciplinary intervention, already present in the first session of the speech therapist with the boy, while the psychologist was talking to the parents. In addition to Lúcio at that moment needing the presence of his mother, his speech had no limits, and only the presence of the body made contours/edges. In this sense, the acceptance of the suggestion of the psychologist that the speech therapist allows the parents to participate in the sessions of the child, reflected in listening to the symptom as part of the family dynamics, in this case, the condition of the boy not being able to separate himself from the body of the parents.

As the parents took a position on the behavior of their son, Lúcio also presented the demand for limits. This was evidenced in the scenes of playing, where the “no” appeared as a ban through the word, surpassing the real of the body. During the sessions with Lúcio and the father, surrounded by interaction and play, the father also perceives the “no” said by the psychologist and expresses that the son is now able to play with other children, as he waits for his turn, lends the toys and accepts better the “no” offered by him. The demand for limits of Lúcio also emerged in the work with the speech therapist and in interdisciplinary exchanges where limits could be better delineated. With this, the unbearable, presented in the first session, became supported in the symbolic act.

So, it is emphasized that from the theoretical-technical specificities that each professional launches on the presented demand, a shared practice of dialogue and planning of interventions can arise, allowing the enrichment of the work^38-40. The interdisciplinary action culminated in the evolution of Lúcio in different aspects, such as the organization in play, the alternation of turns and his first-person speech, which denotes an authorization of the subject to enunciate himself as "I" in the speech, no longer trapped, glued to the maternal discursive field, giving indications of the separation process in operation.

Finally, in relation to the number of sessions established for the development of the research, it was observed that, from the speech point of view, 12 sessions were a limited period to work on the language and speech issues presented by the children. It should be noted that the understanding of verbal language did not change in the cases (Bento and Wagner) who received only speech therapy, an important element to be considered for future research. In the psychoanalytic area, on the other hand, it is proposed to think that interventions are carried out within a logical time. In this way, achieving what was proposed, starting from the assumption that the subject of the unconscious is timeless and that every intervention has its effects on the analytical process.

Regarding the number of children participating in the study, it was considered sufficient, demonstrating coherence with the methodological proposal used, once in qualitative research the repetition of data would generate sample saturation. However, it is known that it is necessary to carry out future research with other samples, in order to reach a generalization of the findings.

Conclusion

The interdisciplinary dialogue showed a positive effect on the evolution regarding the cases of Gabriel and Lúcio. In this way, a psychoanalytic look at the cases that received only speech therapy (Bento and Wagner) would allow intervening with the parents, listening to their phantasmagorical speech and working with the children on their questions regarding the presented problem. In addition, in relation to Wagner’s case, psychoanalytic work would contribute to communication with the school.

This study showed the importance of dialogue between Psychoanalysis and Speech areas in cases presented with delayed oral language. The intertwining of these areas made possible an opening to the dialogue that permeates the processes of subjectivation of the child traversed in and by language.

Then, it is believed that speech therapists can also use listening in their clinic, in order to welcome children, regardless of their therapeutic approach, and also cast a glance at the parents, because it is in their listening and in the construction of this bond that there is a possibility of better management and targeting of the treatment.

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Publication Dates

• Publication in this collection
  24 Oct 2022
• Date of issue
  2022

History

• Received
  14 May 2022
• Accepted
  26 July 2022