Cognitive stimulation in socioeconomically disadvantaged children with neurodevelopmental disorders: a case series

The study addresses how living in socioeconomically disadvantaged environments—characterized by poverty, violence exposure, malnutrition, and social exclusion—negatively affects children’s brain development and cognitive functions (language, memory, executive functions). It highlights that children with neurodevelopmental disorders (NDDs)—including ADHD, specific learning disorders (SLD such as dyslexia and dysgraphia), and autism spectrum disorder (ASD)—may be particularly vulnerable, facing compounded risks in such contexts. Given evidence that cognitive stimulation can leverage brain plasticity and may be especially beneficial in low-SES populations, the purpose was to evaluate the impact of a group-based cognitive stimulation program on cognitive outcomes in four Guatemalan fifth-graders with different NDDs, using a larger neurotypical cohort as reference. The hypothesis was that the program would improve cognitive development in all children at risk of social exclusion, with larger benefits in those with NDDs due to their greater need for specific educational support.

Prior work links low socioeconomic status with adverse physiological and psychological effects on child development, including alterations in brain structure and function and deficits in language, memory, and executive functions. Socioeconomic deprivation is associated with higher prevalence of NDDs, potentially via chronic stress, violence exposure, malnutrition, and limited resources. The paper reviews diagnostic features and common impairments in ADHD, SLD (dyslexia, dysgraphia, dyscalculia), and ASD, including social cognition difficulties (emotion recognition, theory of mind, social attention) prominent in ASD. Evidence supports neuropsychological stimulation programs improving cognitive, social, and emotional functioning and suggests greater benefits in low-SES populations; however, research specifically focusing on low-SES children with NDDs is scarce. Reading promotion programs can improve reading and related linguistic skills but may not target broader executive or social-cognitive domains.

Design: Descriptive case series with reference groups. Participants: Four Spanish-speaking, non-bilingual fifth-grade children from vulnerable areas of Guatemala City with NDDs: Case 1 (male, 11; SLD dyslexia/dysgraphia; experimental group), Case 2 (female, 14; ASD, Asperger type; experimental group), Case 3 (male, 11; ADHD; control group), Case 4 (male, 12; SLD dyslexia; control group). Socioeconomic profiles indicated severe or moderate food insecurity and low household income. A neurotypical reference cohort (n=126; 42.4% female; age 10–11) from the same schools was randomly assigned to experimental (n=66) or control (n=60) conditions. Inclusion criteria for neurotypicals: fifth grade, no clinical history, no grade repetition, and reading and nonverbal intelligence above the 5th percentile (L-3-DEs, TONI-2). Measures: Pre- and post-intervention comprehensive neuropsychological battery over three 45-min sessions at each time point. Language: TOKEN Test (verbal comprehension), phonological and semantic verbal fluency, Inter-American Reading Series L-3-DEs (vocabulary, speed, comprehension). Attention/Executive Functions: Nesplora Aula School (attention, inhibition, impulsivity, response speed), Nesplora Ice Cream (working memory, flexibility, planning), TONI-2 (nonverbal intelligence). Social Cognition: NEPSY-II subtests (Emotion Recognition, Theory of Mind). Intervention: Tablet-based cognitive and emotional stimulation protocol delivered via NeuronUP platform, targeting attention, language, executive functions, and social cognition. Structure: 24 sessions across three difficulty levels; both groups used tablets. Procedure: Baseline assessment in schools by trained professionals; environmental distractions varied by site. Interventions delivered twice weekly (two 30-min sessions per week) for 12 weeks (24 sessions) in group format. The control group performed habitual reading activities during the same period. Post-intervention assessment occurred one week after the final session. Ethical approval: Universidad del Valle de Guatemala Ethics Committee (Protocol #56, May 31, 2021). Data analysis: Intrasubject clinical significance determined by comparing pre/post percentile scores with qualitative categories (Korkman et al., 2014). Delta scores (post minus pre percentiles) computed for all variables. Each case’s delta was standardized against the mean and SD of the matched reference group (experimental or control); ±1 SD threshold indicated significant difference.

- Experimental group showed significant improvements in executive functions (inhibition, flexibility, planning). - NDD cases in the experimental group (Cases 1 and 2) improved social cognition more than their neurotypical experimental peers and more than NDD cases in the control group. - Case-level clinical significance (pre/post percentiles): • Case 1 (SLD; experimental) improved on 8 measures: phonological fluency, attention, inhibitory control, impulsivity, response speed, cognitive flexibility, planning, emotion recognition; decrease only in language comprehension (normal to slight deficit). • Case 2 (ASD; experimental) improved on 5 measures: phonological fluency, inhibitory control, impulsivity, planning, theory of mind; decrease in nonverbal intelligence but remained in normal range. • Case 3 (ADHD; control) improved on 3 measures: language comprehension (to talented), phonological fluency (severe to moderate deficit), reading skills (to talented); decreases in inhibitory control (normal to mild deficit) and emotion recognition (normal to moderate deficit). • Case 4 (SLD; control) improved on 3 measures: reading skills (moderate deficit to normal), working memory, emotion recognition (severe to mild deficit); decreases in semantic fluency, attention, inhibitory control, impulsivity. - Standardized delta comparisons to reference groups (±1 SD threshold): • Case 1: significant gains in impulsivity (+1.5 SD), cognitive flexibility (+1.0 SD), planning (+1.6 SD) versus experimental reference group. • Case 2: significant gain in working memory (+1.5 SD); smaller-than-group effects in semantic fluency and nonverbal intelligence (both ≈ −1 SD). • Case 3: greater increases than control reference in language comprehension (+2.0 SD), planning (+1.2 SD), nonverbal intelligence (+1.9 SD), but lower than reference in attention (−2.0 SD), inhibitory control (−1.4 SD), and impulsivity (−1.1 SD). • Case 4: no significant differences versus control reference, except a decline in semantic fluency (−1.4 SD). - Overall, the cognitive stimulation program yielded more and larger improvements for NDD cases than for neurotypical children, whereas the reading program mainly enhanced linguistic/reading skills and did not generalize to executive or social cognition for NDD cases.

Findings support the hypothesis that a structured, tablet-based cognitive stimulation program can improve executive functions and social cognition among children with NDDs living in socioeconomically disadvantaged contexts. The experimental NDD cases exhibited broader and more clinically meaningful gains with fewer declines than NDD controls, indicating that specialized stimulation may be particularly potent for this population and can help narrow developmental gaps relative to peers. Improvements in theory of mind for the ASD case underscore potential benefits for socially relevant cognition that can meaningfully impact quality of life. In contrast, the reading program benefited language and reading skills but did not address executive control or social cognition; in NDD controls, some EF and socio-cognitive measures declined relative to their control peers. Group-based delivery, though potentially less tailored than individualized interventions, appears feasible and beneficial in resource-limited school settings. The results align with prior literature on cognitive stimulation effectiveness and extend evidence to low-SES, high-vulnerability contexts.

This case series demonstrates that a comprehensive, group-delivered cognitive stimulation program can significantly improve executive functions and social cognition in socioeconomically disadvantaged children with NDDs, with effects exceeding those observed in neurotypical peers. Reading promotion activities enhanced language/reading but did not generalize to broader cognitive domains and appeared less effective for NDDs. The study underscores the importance of accessible, specialized neuropsychological interventions in low-resource settings and suggests these programs can help reduce developmental disparities. Future research should involve larger, well-matched samples, optimize intervention tailoring within scalable group formats, and examine durability of gains and academic/functional outcomes over time.

- Very small NDD sample (four cases), limiting generalizability. - Uncontrolled testing environments in schools (noise, visual distractions, cramped spaces) may have affected performance. - Lack of locally normed neuropsychological tests for Central American populations necessitated using Spanish norms, potentially impacting score interpretations (mitigated by intrasubject analyses). - Group-based intervention may be less adaptable than individualized programs, potentially constraining individual-specific gains. - Absence of long-term follow-up to assess maintenance of improvements.