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Evaluating pragmatic language impairments

in children

Talk given at Millennium Conference on Specific Language Impairment in Children,

Dunmurray, Belfast, 7/11/00by

Dorothy BishopUniversity of Oxford

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Specific language impairment

language does not follow normal developmental course

language test scores substantially below nonverbal ability

language problems interfere with daily living/academic achievement

not due to hearing loss, physical abnormality, acquired brain damage

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Social interaction in SLI

traditional view

children with SLI may be impaired in social interaction, but this is a secondary consequences of their difficulties with oral language expression and comprehension

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Impact of language on social and behavioural

development: studies of SLI

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Social interaction and language status

(Rice and colleagues)preschool children with language or

speech impairments half as likely to be addressed by their peers

as children with age-appropriate language. when addressed by other children, less

likely to respond fewer initiations to other children less popular than other children

similar pattern for children with ESL

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Gertner et al, 1994

0

1

2

3

4

5

6

7

normal controlN = 9

speech/lang impairedN = 12

ESLN = 10

no

min

atio

ns

negative

positive

popularity predicted by receptive language score

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Hadley & Rice, 1991

“Preschoolers behave as if they know who talks well and who doesn’t, and they prefer to interact with those who do”

J. Speech and Hearing Research, 34, 1308-1317

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Challenges to conventional view of social interaction deficits as

secondary

some children with SLI show:

lack of correlation between expressive and receptive language and social impairments

pragmatic deficits that go beyond immaturity

deficits in nonverbal communication

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•Phonology and syntax unimpaired •Verbosity•Comprehension deficits for connected speech•Word finding deficits•Atypical word choices•Inadequate conversational skills•Speaking aloud to no one in particular•Poor maintenance of topic•Answering besides the point of a question

Semantic-pragmatic deficit disorder

Rapin 1996

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National survey of 242 language-impaired

childrenRandom sample of 7-year-olds attending language units in England

Direct assessment supplemented by teacher report

10% fell in cluster corresponding to “semantic-pragmatic disorder”

pragmatic problems not picked up on standardized tests

Conti-Ramsden et al, 1997, J Speech, Language & Hearing Research

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Pragmatic difficulties Can be seen as difficulty in selecting

appropriate message or interpretation

e.g. same child may sometimes give too much extraneous information, other times not enough information

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Task thought to reflect children’s ability to use their language skills for

effective communication

Bishop & Adams, 1991

Referential communication

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Conclusions from referential communication task

Many children with SLI had difficulty in formulating informative messages

However, little relationship between performance on this task and communicative adequacy in conversation

Concrete situation of referential communication task seemed to make it easy for some children with pragmatic problems

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Development and Psychopathology, 2000

Conversational responsiveness in specific language impairment: evidence of disproportionate

pragmatic difficulties in a subset of children

Dorothy Bishop, Janet Chan, Cathy Adams, Joanne Hartley ,

& Fiona Weir

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Goals

find more objective way of identifying subgroup of children with pragmatic difficulties

discover more about which aspects of communication lead to clinical impression of ‘semantic pragmatic disorder’

test whether these are different from developmental immaturities

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Sample9 in each groupSLI-T: typical SLIPLI: “pragmatic language impaired”CA control, age and IQ matched

Groups 1 to 3, mean age 90 months

LA control, matched on receptive/expressive raw scoreLA controls, mean age 62 months

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Observational methods

Analysis of language-impaired children’s conversation (ALICC)Turn-by-turn coding of 8-10 minutes of videoed conversationAnalyse meshing between adult’s solicitations and child’s

responses

Bishop et al, 2000, Development and Psychopathology

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Coding of response meshing

adequate: response fits expectations of solicitation

inadequate: vague, underspecified, or apparently reflecting poor understanding of the words in a question

pragmatically inappropriate: impression of oddity rather than immaturity

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Inadequate responses*

response that is vague , over-general, semantically underspecified

A: what did you use as a 'bat?C: we had one of 'these things that goes up

and down 'there, (gestures) and then it goes 'round like 'that.

*************************************** N.B. child’s age is not taken into account

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Pragmatically inappropriate responses

extended response that contains material that is irrelevant, repetitive or bizarre(child shown photo of boy examined by

doctor) A: what do you think is wrong with that 'boy?

C: i think he might have fallen into the 'water, on january the 'sixth.

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Pragmatically inappropriate responses

tangential response

A: have 'you ever been to the doctorC: i had a 'apple a day.

the response “no” can be inferred, but only with some difficulty.

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Pragmatically inappropriate responses

failure to take prior conversation into account

A: how did you ‘get to blackpool?C: in the 'car.A: ‘n what about when you went to

'france?C: it was 'hot.

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Adequacy of responses

0% 20% 40% 60% 80% 100%

PLI

SLI-T

CA control

LA control

pragmaticallyinappropriateinadequate

adequate

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Nonverbal responses

0

5

10

15

20

25

30

35

40to

tal

NV

1 2 3 4N n

on

verb

al re

spon

ses

LA con CA con SLI-T PLI

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Response adequacy in relation to use of nonverbal responses

N nonverbal response

Low (0 to 2)1 CA , 5 SLI-T, 6 PLI

Medium (3 to 9)4 LA , 5 CA , 1 SLI-T,

2 PLIHigh (10 to 34)

5 LA , 3 CA, 3 SLI-T, 1 PLI

0% 50% 100%

low

med

high

pragmatically inappropriateinadequateadequate

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Pragmatics and social interaction in SLI

evidence that for some language-impaired children, pragmatics is an area of disproportionate difficulty

is this really autistic disorder?see Brook & Bowler, 1992

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Specific Language

Impairment

Autisticdisorder

Pervasive developmental disorder

•several areas of impairment•deviant rather than just delayed

Specific developmental disorder

•single area of impairment• delayed rather than deviant

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autisticdisorder

languagesocial interaction

interests/repetitive behaviour

Triad of impairments

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Evidence that pragmatic deficits are a hallmark of

autistic disorder

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Bartak et al, 1975

• impaired verbal comprehension • boys, aged 5-10 years• nonverbal IQ of 70+• normal hearing• no neurological disease

19 autisticdisorder

23 receptivelanguagedisorder

5 mixed

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Bartak et al: language use

0 0.2 0.4 0.6 0.8 1

pronoun reversal (ever)

echolalia (ever)

stereotyped utterances (ever)

metaphorical language (ever)

inappropriate remarks

no spontaneous chat

fails to respond to questions

never used gesture

proportion

autistic receptive SLI

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Bartak et al: nonlanguage

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

difficult adaptation to new situations

quasi-obsessional activities

ritualistic activities

resistance to change

attachment to odd objects

lacks imaginative play

proportion

autistic receptive SLI

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Contemporary view of autism

Pragmatic difficulties a hallmark of communication disorder

Social and imaginative deficits are not simply secondary to the language problems

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Should all cases of pragmatic impairment be categorised with autism?

No, becauseevidence of intermediate cases from

studies of autistic childrensome children with pragmatic

difficulties have little evidence of autistic features

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autistic-like behaviours seen in SLI at follow-up

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

stereotyped utterances

metaphorical language

no group participation

fails to show sympathy

stereotyped mannerisms

lacks imaginative play

rituals

proportion

autistic receptive SLI

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Mawhood 1995

Follow-up of original sample into adulthood

Compared on psychometric and behavioural data

Discriminant function analysis

See also Howlin et al, 2000

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(subject DLD8, aged 22 years)

"In all aspects of self-care he was entirely independent and he could use a telephone and manage his finances himself. Most of his spare time was spent pursuing his preoccupation with buses and his less intense interest in CB radio. He spent a lot of time hanging around bus stations, going on bus journeys when he could afford it, and looking at bus magazines. His social overtures were somewhat limited and he would speak if spoken to but would not make the first move. There were two friends that he visited regularly; one shared his interest in buses, the other was interested in CB radio. These relationships were clearly selective, did involve some apparent pleasure in each other's company, and some sharing of confidences, but there was still nonetheless a slightly odd quality to them because of their restricted range of interests. He did not appear to be lonely." (p. 384).

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Children’s Communication Checklist

BISHOP, D. V. M. 1998. Development of the children's communication checklist (CCC): a method for assessing qualitative aspects of communicative impairment in children.

Journal of Child Psychology and Psychiatry, 39, 879-891.

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Sample for CCC study

subset of original sample from Conti-Ramsden et al (1997)

staff from 52 language units agreed to participate, giving checklist data for 76 pupils (32% of the whole cohort)

mean age at checklist completion was 8.25 years (range 7.55 to 9.83 years)

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Diagnostic information from school

Coded as definite/possible/not applicablesemantic-pragmatic disorderautistic disorder / infantile autismautistic features / autistic spectrum disorder Asperger's syndromepervasive developmental disorder/ PDDNOS(also asked about SLI, hearing, mental

handicap, learning disabilities, home language background)

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Exclusions

definite autistic disorder (N = 3)permanent hearing loss (N = 2)nonverbal IQ below 80 (N = 6)physical handicap (N = 1)bilingual home background (N = 4) no diagnostic information (N = 1)

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Semantic-pragmatic, pure: (N = 14) semantic-pragmatic disorder: possible/definiteno autistic disorder, autistic features or

Asperger's syndrome

Semantic-pragmatic, plus: (N = 8) semantic-pragmatic disorder: possible/definite + possible or definite autistic features, autistic

spectrum disorder, or Asperger's syndrome

Other SLI: (N = 37)Includes dev. language disorder, dev. verbal

dyspraxia, language delay

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Subscales in CCC

SpeechSyntax

Social relationships

Interests

Inappropriate initiation

Coherence Stereotyped

languageUse of contextRapport

pra

gm

atic co

mp

osite

Reliability = .80

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Sample items: Stereotyped conversation

• pronounces words in an over-precise manner: accent may sounds rather affected or "put-on", as if child is mimicking a TV personality rather than talking like those around him

• often turns the conversation to a favourite theme, rather than following what the other person wants to talk about

• includes over-precise information in his talk, e.g. will give the exact time or date of an event. For instance, when asked "when did you go on holiday" may say "13th July 1995" rather than "in the summer".

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0

2

4

6

8

10

12

14

SLISP pureSP+

Pragmatic composite

freq

uen

cy

Checklist meansSP plus SP pure SLI

A. speech 30.1 30.6 26.5B.syntax 30.3 29.2 28.7C.inappropriate init. 25.0 25.9 28.0D.coherence 23.6 25.5 28.7E.stereotyped conv. 21.4 23.9 27.5F.use of context 22.3 24.2 28.5G.rapport 25.0 29.1 31.0H.social 25.3 28.9 29.9I.interests 28.3 30.8 31.8

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significant minority of language-impaired children do have pragmatic problems

these are not readily explained as secondary consequences of other language limitations

pragmatic impairments sometimes, but not always, associated with autistic features

Intermediate conclusions

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Specific Language

ImpairmentAutisticdisorder

semanticpragmaticdisorder?

Is there a distinctive syndrome of semantic-pragmatic disorder?

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Evidence against a syndrome

little support for clustering of semantic and pragmatic impairment

nonverbal limitations a common feature in language-impaired children

pragmatic difficulties not confined to those with good formal language skills

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suggests…..

pragmatic language impairment is a variable correlate of communication problems, rather than defining a specific subgroup

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language structure

language use

+

+

_

_

phonologic-syntacticdeficit

semantic-pragmaticdeficit

The view from contemporary classifications

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language structure

language use

+

+

_

_

phonologic-syntacticdeficit

semantic-pragmaticdeficit

Alternative dimensional view

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Current study (ongoing)

Is pragmatic language impairment (PLI) on a continuum with autistic disorder?

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Participants

22 children recruited from language units and special schools for SLI13 selected as having low scores on

‘pragmatic composite’ of CCC9 with high scores on ‘pragmatic

composite’ of CCC10 age- and IQ-matched normal

controls

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Standard diagnostic procedures for autistic

disorder Autism diagnostic interview (ADI): with

parents, approx 3 hours focus on behaviour at age 4-5 years

Autism diagnostic observation schedule (ADOS): with child, 45 mins focus on current behaviour

Autism screening questionnaire (ASQ): completed by parents, 40 items

_____________________________________________ low CCC (PLI) high CCC (SLI)

_____________________________________________Meeting criteria forautism on all 3 measures 2 (15%) 0

Meeting criteria on 2/3 4 (30%) 3 (33%)measures

Meeting criteria on 1/3 4 (30%) 2 (22%)measures

PDD on 1 or more measures 1 (8%) 4 (44%)

Normal on all 2 (15%) 0_____________________________________________

How many children are autistic?NB preliminary data - still under analysis

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Are PLI and autism the same thing?

Some children in special schools for SLI do meet criteria for autism

Many have some features of autismHowever, this is true for those who

do not appear pragmatically impaired in clinical terms

Repetitive behaviour is not a feature for most of these children

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autisticdisorder

languagestructure

social useof language

interests

Asperger’sdisorder

specificlanguage

impairment

P L I (semantic-pragmatic disorder)

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Recommendations:children with pragmatic

difficulties DO NOT assume problems are just

secondary manifestations of SLI DO NOT assume ‘this is autism’

(cf. Advice from NAS)

BUT DO refer for fuller evaluation of possible

autism/PDD

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for references see:

epwww.psych.ox.ac.uk/oscci