pragmatic language difficulties in children with hyperactivity and attention problems: an integrated...

INT J LANG COMMUN DISORD, JANUARY–FEBRUARY 2014,VOL. 49, NO. 1, 15–29

Review

Pragmatic language difficulties in children with hyperactivity and attentionproblems: an integrated review

Benita C. Green†, Katherine A. Johnson† and Lesley Bretherton†‡§†Melbourne School of Psychological Sciences, University of Melbourne, VIC, Australia‡The Royal Children’s Hospital Melbourne, Parkville, VIC, Australia§Murdoch Children’s Research Institute, Parkville, VIC, Australia

(Received December 2012; accepted July 2013)

Abstract

Background: Diagnostic criteria for attention deficit hyperactivity disorder (ADHD) suggest a range of difficultiesin the pragmatic aspects of language, including excessive talking and interrupting others. Such difficulties havebeen periodically reported over several decades in studies on the language abilities of children with features ofADHD, yet a comprehensive review of the literature has been lacking.Aims: This review aims to integrate evidence from several lines of research from 1979 to the present on pragmaticlanguage difficulties in children with ADHD or symptoms of ADHD.Methods & Procedures: A comprehensive search of empirical literature on pragmatic language in children withADHD or symptoms of ADHD was conducted using PsycINFO and PubMed databases and through followingup relevant references cited in articles. Literature was reviewed with respect to the nature and extent of pragmaticlanguage difficulties in ADHD.Outcomes & Results: Thirty studies met the review inclusion criteria, including recent questionnaire studies,observational studies of children’s communication patterns, and studies of higher-level language comprehensionand production. The studies indicate a consistent profile of pragmatic language impairments in children withfeatures of ADHD, particularly in the areas of excessive talking, poor conversational turn-taking, and lack ofcoherence and organization in elicited speech.Conclusions & Implications: Pragmatic language difficulties are common in children with features of ADHD. Thesedifficulties are consistent with deficits in executive function that are thought to characterize ADHD, thus providingsome support for the theory that executive function contributes to pragmatic language competency. As yet thereis very little empirical evidence of specific relationships between particular aspects of pragmatic language andparticular domains of executive function. Given the importance of pragmatic language competency for children’ssocial and academic functioning, pragmatic language abilities should be considered during clinical assessment forADHD and targeted for intervention.

Keywords: pragmatic language, communication, attention deficit hyperactivity disorder (ADHD) symptoms, hyper-activity, inattention.

What this paper adds?What is already known on this subject?Diagnostic criteria for ADHD imply that children with features of this disorder may exhibit difficulty with pragmaticaspects of language, particularly in excessive talking, interrupting others, and failing to respond appropriately toverbal questions and instructions. Such difficulties have indeed been reported by various researchers since the 1980sbut a comprehensive review of relevant research on this topic is lacking.

What this paper adds?This review integrates evidence from almost 40 years of research. Findings indicate that children with features ofADHD frequently have pragmatic language difficulties compared with typically developing children, mainly inadopting appropriate listener and speaker roles during social interactions, and in producing coherent, well-organized

Address correspondence to: Benita C. Green, Melbourne School of Psychological Sciences, University of Melbourne, VIC 3010, Australia;e-mail: [email protected]

International Journal of Language & Communication DisordersISSN 1368-2822 print/ISSN 1460-6984 online C© 2013 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12056

16 Benita C. Green et al.

speech. These difficulties are consistent with executive function deficits, thus providing support for the theorythat executive functions contribute to effective pragmatic language use. These pragmatic language difficulties likelycontribute to the impaired social and academic functioning reported in children with features of ADHD.

Introduction

Pragmatic language (PL) refers to the appropriate andeffective use of language in interpersonal contexts andis of central importance for children’s ability to func-tion well at home, school and with their peers (Russell2007, Russell and Grizzle 2008). It can be distinguishedfrom the structural aspects of language that have beentraditionally considered relatively independent of con-text: phonology, syntax and semantics (Camarata andGibson 1999). Difficulties in PL can be seen in variousbehaviours, such as talking too much, poor turn-takingin conversation, failure to adapt a message to the needsof a listener, failure to respond to verbal cues from oth-ers, over-use of stereotyped phrases, and difficulty un-derstanding sarcasm, jokes and metaphors (Bignell andCain 2007, Camarata and Gibson 1999, Perkins 2010,Russell 2007).

PL problems can occur even when a child showsnormal structural and semantic language abilities, as in-dicated by normal scores on traditional language tests(Bishop and Baird 2001). Many children with high-functioning autism exemplify this pattern of dispropor-tionately high PL difficulties in relation to relativelyintact structural language ability (Norbury et al. 2004).As Martin and McDonald (2003) explain, the struc-tural aspects of language are insufficient to character-ize the range of meanings, including inferred meaningsthat arise whenever language is used during a particu-lar communicative exchange. The pragmatic dimensionof language is needed to interpret an utterance such as‘the rubbish bin is full’ as an indirect request to takethe rubbish out, rather than as a gratuitous statementof fact: to understand the communicative intent of theutterance, the listener relies not just on semantic andsyntactic knowledge, but also on knowledge of relevantfeatures of the context and of the speaker.

This review examines the empirical literature relat-ing to PL difficulties in children with attention deficithyperactivity disorder (ADHD), or behavioural featuresof ADHD. ADHD is a common neurodevelopmen-tal disorder, with a worldwide prevalence estimated at5.29% in children and adolescents (Polanczyk et al.2007). It is characterized by persistent inattention, im-pulsiveness and/or hyperactivity that is inappropriatefor age and occurs in a range of settings. The problem-atic behavioural symptoms cause significant impairmentin school, home and social functioning (American Psy-chiatric Association 2000). In particular, interpersonal

and social difficulties are well documented in childrenwith ADHD and include frequent conflicts with adultsand peers, rejection by peers and lack of friendships(Nijmeijer et al. 2008). It seems likely that social dif-ficulties in ADHD are related to difficulties with thepragmatic use of language in social contexts (Cama-rata and Gibson 1999, Leonard et al. 2011). For in-stance, PL is typically sequenced in relation to others’language, and is demonstrated during successful peerinteractions when children join a game, maintain aconversation or resolve a conflict (Fujiki and Brinton2009).

Recently there has been increasing recognitionamongst researchers that behavioural and cognitive fea-tures associated with ADHD are distributed in the pop-ulation as a whole, with the syndrome of ADHD repre-senting the extreme end of a continuum (Fair et al. 2012,Shaw et al. 2011). In keeping with this dimensional viewof ADHD, the review focuses on PL difficulties in chil-dren with symptoms of ADHD, as well as those whomeet diagnostic criteria for the disorder. The purpose isto identify any specific aspects of PL difficulty that arerelated to the core behavioural features of ADHD. Ata theoretical level, this will help to elucidate the com-plex nature of PL problems and the range of potentialinfluencing factors, while at a more practical level it willprovide a basis for targeted treatment of PL difficultiesfor children with ADHD.

The review is organized as follows. First, the the-oretical background regarding potential relationshipsbetween PL and ADHD is presented, followed by anoutline of the scope of the review and guiding researchquestions. Second, the empirical literature is reviewed,organized in subsections according to the methods em-ployed in the various studies. Finally, conclusions arepresented with reference to the research questions.

Theoretical background

Many of the behavioural symptoms of ADHD de-scribed in the DSM-IV (American Psychiatric Associ-ation 2000) can be viewed as pragmatic deficits. Forexample, Camarata and Gibson (1999) point out thatthe following DSM-IV criteria are directly or indirectlyrelated to PL deficits: often does not seem to listen whenspoken to directly; often talks excessively; often has dif-ficulty awaiting turn; and often interrupts or intrudeson others.

Pragmatic language and ADHD symptoms 17

Several researchers have proposed that PL difficul-ties in children with ADHD can be attributed to theirpresumed deficits in executive function (Perkins 2010,Tannock and Schachar 1996, Westby and Cutler 1994).‘Executive function’ is an umbrella term that refers to arange of interrelated neurocognitive processes that allowan individual to behave in a purposeful, goal-directedmanner. Specific domains of executive function havebeen proposed and include attentional control (e.g. se-lective and sustained attention), response inhibition,cognitive flexibility (e.g. working memory, changingstrategies), and goal-setting (e.g. initiate and organizeactivity) (Willcutt et al. 2005).

In general terms, executive function is argued tocontribute to PL ability by enabling an individual to re-spond adaptively and flexibly to the dynamic demandsof social communication (Martin and McDonald 2003).More specifically, in order to hold a coherent reciprocalconversation one needs to pay attention to and remem-ber what one’s conversational partner is saying, whichrelies on the executive functions of sustained attentionand working memory (Geurts et al. 2010). At the sametime, one needs to inhibit excessive talking, and to en-sure that one’s contributions are relevant, which relies onthe executive functions of response inhibition and plan-ning (Tannock and Schachar 1996, Westby and Cutler1994). Pragmatic difficulties in understanding sarcasmand figurative expressions are also consistent with ex-ecutive function deficits, in that they potentially reflectinadequate monitoring and evaluation of contextual in-formation that would support an appropriate non-literalinterpretation (Bignell and Cain 2007, McInnes et al.2003). Likewise, executive function deficits in planning,organizing and monitoring have been proposed to ac-count for higher-level expressive language difficulties inchildren with ADHD, such as difficulty tailoring speechto meet the needs of a listener when retelling a story(Purvis and Tannock 1997).

Despite the theoretical relationships between PL andexecutive function, there has been very little empiricalwork investigating these potential relationships with re-spect to ADHD. This is an important area for futureresearch. At this stage, it is necessary to obtain a clearerunderstanding of the profile of PL difficulties associatedwith ADHD symptoms so that future research can in-vestigate these specific difficulties in relation to aspectsof executive function.

In addition to executive function, structural lan-guage abilities also contribute to PL competency(Perkins 2010). This is an important consideration giventhat up to one-third of children with ADHD could beconsidered to have specific language impairment (SLI)(Mueller and Tomblin 2012, Tannock and Schachar1996). Several researchers have noted that expressive

and receptive problems with the structural aspects of lan-guage are found mainly in those children with ADHDwho also have co-morbid reading difficulties, while dif-ficulties with PL seem to occur more generally in theADHD population (Cohen et al. 2000, Geurts and Em-brechts 2008, Tannock and Schachar 1996). There is asyet no empirical research on whether the PL problems ofchildren with ADHD differ in kind or extent from thoseof children with ADHD and co-morbid SLI. Childrenwith ADHD and co-morbid SLI may have PL diffi-culties that reflect both conditions. For instance, SLImay contribute to difficulties in choosing and usingwords accurately, adapting syntactic structure accordingto context, and deriving meaning from others’ utterances(Adams et al. 2009, Perkins 2010). ADHD symptomsmay contribute to somewhat different PL difficulties,such as excessive talking and disorganized speech.

A full treatment of the complex issues around co-morbidity of ADHD with SLI is outside the scope ofthis review. Limiting the review to studies of childrenwith ADHD symptoms without co-morbid SLI or read-ing difficulties allows a clearer characterization of the PLdifficulties that are specifically associated with ADHDsymptoms rather than PL difficulties that may reflectthe multiplicative or additive effect of two separate dis-orders.

The research on PL in relation to ADHD symp-toms has tended to fall into several separate lines ofresearch, partly because the multidimensional conceptof PL allows for various research methods. Recentlya number of questionnaire studies of PL in childrenwith ADHD have been conducted, most of whichused the Children’s Communication Checklist (CCC)(Bishop 1998), or the revised version of this question-naire (CCC-2) (Bishop 2003). In addition, there is anearlier body of research that examined qualitative as-pects of children’s social communication, and anotherthat examined higher-order language abilities in childrenwith ADHD. Currently an integrative review of liter-ature across these separate lines of research is lacking.Consequently this review includes all identified ques-tionnaire studies of PL in children with ADHD, orsymptoms of ADHD, along with any observational andexperimental studies that directly implicate pragmaticaspects of language in this population. The guiding re-search question is: what is the extent and nature ofPL difficulties in children with ADHD or symptomsof ADHD? A secondary research question is whetherthere is any empirical evidence to support the theorythat deficits in executive functions underlie the PL dif-ficulties associated with ADHD symptoms. This latterquestion necessarily refers to the small subset of the stud-ies that have included measures of aspects of executivefunction.


Previous reviews of pragmatic difficulties in ADHD

Several previous reviews have been conducted on com-munication difficulties in ADHD. Most recently, Geurtset al. (2010) provided a brief review of the five question-naire studies published by 2010 that specifically referredto PL in ADHD. Four of these studies used the CCCor CCC-2. Geurts et al. concluded that the five stud-ies formed a small but consistent body of evidence thatchildren with ADHD have PL impairments relative totypical children, but less severe than children with anautism spectrum disorder (ASD). Prior to the use of theCCC, several reviews from the 1990s identified a mod-erately large body of evidence that children with ADHDexperience PL difficulties alongside difficulties in otheraspects of speech and language (Baker and Cantwell1992, Damico et al. 1999, Tannock and Schachar 1996).These reviews included empirical studies of children’slanguage use in various interactive communication tasksand concluded that children with ADHD exhibit a rangeof pragmatic deficits, in particular: excessive verbaliza-tion; confusing and disorganized discourse; and diffi-culty managing topics in conversation. The reviews fromthe 1990s provide useful overviews of earlier research onpragmatic difficulties in children with ADHD, but werenot specifically focused on PL and are somewhat lack-ing in detail regarding characteristics of the samples,empirical methods used in different studies.

Method

Search strategy

In view of several different terms in use that implicatethe concept of PL, and likewise several different termsrelevant to ADHD symptomatology, the initial searchstrategy used a range of search terms. Initial searchesin PsycInfo and PubMed databases used search terms‘communication’, ‘pragmatic’, ‘language’, ‘conversation’and ‘ADHD’, ‘ADD’, ‘hyperactivity’, ‘attention’, and‘inattention’. Abstracts of retrieved articles were read tocheck for relevance and the reference lists of articles werealso checked to identify further relevant studies. Studiespublished from 1970 to the present were included. Inall, 30 empirical papers were identified that examinedaspects of PL in children with a diagnosis of ADHD, orsymptoms of ADHD.

Inclusion criteria

Studies were included if the participants were childrenover 3 years of age and up to 18 years of age, and hadeither symptoms of ADHD or a diagnosis of ADHD,ADD, hyperkinesis or hyperactivity. Thus, we includedstudies that focused on diagnosed children as well asthose that focused on non-diagnosed children rated as

having hyperactivity and/or attention problems. Thisis in keeping with the dimensional view of ADHD, inwhich the syndrome of ADHD represents the extremeend of a continuum of symptoms in the population(Shaw et al. 2011). The review included empirical stud-ies that reported on aspects of language that could beconsidered pragmatic, under a broad conception of PLas the appropriate use of language in social contexts.Studies were excluded if they focused primarily on thestructural aspects of language (phonology, syntax, se-mantics), reading disability or SLI.

Results and discussion

Results are reported and discussed in three sections: (1)studies using questionnaire measures of PL; (2) observa-tional and experimental studies of pragmatic aspects ofcommunication; and (3) experimental studies of high-level language abilities with implications for the prag-matic aspects of language.

Questionnaire studies of pragmatic language (PL)in relation to ADHD

Thirteen questionnaire studies were identified that ex-amined PL in children with ADHD or symptoms ofADHD. These are summarized in table 1. Most wereconducted within the last 10 years and used the CCCor CCC-2. The CCC-2 provides an overall measure ofgeneral communicative competence as well as separatesubscales that measure aspects of PL, and others thatmeasure structural language. Most of the questionnairestudies involved group comparisons, and consistentlyfound that children with ADHD exhibit PL difficultiescompared with typically developing children.

Questionnaire studies of children with a diagnosisof ADHD

Several questionnaire studies compared PL in childrenwith a diagnosis of ADHD and children with variousother clinical diagnoses, particularly ASD. Bishop andBaird (2001) examined whether the CCC could dis-criminate between various diagnostic groups and unex-pectedly found that children with a diagnosis of ADHDexhibited significant PL deficits: they had difficulty withuse of context, coherence of their speech, conversa-tional rapport, inappropriate initiation and stereotypedlanguage. Strikingly, the ADHD group hardly differedfrom children with Asperger’s syndrome on the over-all measure of pragmatic competence, with 86% fallingmore than 2 SDs (standard deviations) below the meanof the normal control group. Several subsequent stud-ies using the CCC-2 likewise found PL difficulties in


Table 1. Questionnaire-based studies of pragmatic language in children with ADHD or symptoms of ADHD

Reference Measures and method Participants: N, age range, groups Main findings regarding pragmatic language

Bignell and Cain(2007)(Study 2)

Parent form of CCC-2Group comparisons

Children with teacher-rated poorattention and/or hyperactivity andseparate control groups (7–11 years):

Hyperactive (n = 16)Poor attention (n = 19)Hyperactive/poor attention (n = 14)Controls (n = 18, 19, 17)

The poor attention and the hyperactive/poorattention groups were impaired on overallpragmatic language relative to their respectivecontrol groups. Hyperactive group was notimpaired

Bishop and Baird(2001)

Parent and teacher forms ofthe CCC

Group comparisons

Clinic-referred diagnosed children andnormal controls (5–17 years):Autism (n = 21)Asperger’s (n = 33)PDD-NOS (n = 43)ADHD (n = 24)SLD (n = 14)NC (n = 31)

ADHD group impaired on the pragmaticlanguage composite scale relative to NC, with86% of the ADHD group more than 2 SDbelow the mean of the NC group; degree ofimpairment equal to Asperger’s andPDD-NOS groups but not as severe as autismgroup

Bruce et al.(2006)

Parent questionnaire FTF(Five to Fifteen)

Diagnosed children with ADHD (n =76) (mean = 11 years)

Majority had difficulty with languagecomprehension, communication andpragmatics compared with normal controls. Atotal of 67% rated as above the 90thpercentile in language problems

Donno et al.(2010)


3DI parent interview;WASI; TEA-Ch; SASI;ToM task

Group comparisons

Community sample of 6–13 year olds‘Persistently disruptive’ (n = 26)Comparison children (n = 22)

Disruptive children had significantly worsepragmatic language skills than thecomparison children. The groups did notdiffer in attention problems, and only two ofthe disruptive children met research criteriafor ADHD, while nine met research criteriafor ASD

Geurts et al.(2004)


Group comparisons

Diagnosed children and normal controls(mean = 9 years):ADHD (n = 50; n = 23)HFA (n = 50; n = 42)NC (n = 50; n = 35)

ADHD group impaired on overall pragmaticlanguage measure and all pragmatic subscalesrelative to NC; less impaired than HFA groupon most pragmatic subscales. Equallyimpaired as HFA on inappropriate initiation

Geurts andEmbrechts(2008)

Parent form of CCC-2(Dutch translation)

Group comparisons

Diagnosed children and TD controls(7–14 years):ADHD (n = 29)ASD (n = 29)TD (n = 29)

ADHD group impaired on overall pragmaticlanguage measure and all pragmatic subscalesrelative to TD; less impaired than ASD onoverall pragmatic measure, but equallyimpaired on coherence and inappropriateinitiation subscales

Helland et al.(2012a)

Parent form of CCC-2(Norwegian adaptation)

Group comparisons

Diagnosed children (6–15 years):ADHD (n = 28)AS (n = 21)TD (n = 18)

A total of 82.1% of the ADHD group metcriteria for pragmatic impairment on theCCC-2. Pragmatic impairments as commonin the ADHD group as the AS group.ADHD group and AS group equallyimpaired on coherence, inappropriate initiationand use of context subscales, but ADHD lessimpaired on stereotyped language andnon-verbal communication

Helland et al.(2012b)

Parent form of CCC-2(Norwegian adaptation)SDQ

Group comparisons

Diagnosed children (6–12 years)ADHD (n = 21)SLI (n = 19)TD (n = 19)

A total of 80% of the ADHD group and 79% ofthe SLI group were impaired on the generalcommunication measure compared with 11%of the TD group. The ADHD and SLIgroups had poorer pragmatic abilities thanthe TD group on all pragmatic subscales ofthe CCC-2

Helland et al.(2012c)

SNAP-IV (Norwegiantranslation);

Single questionnaire itemmeasured pragmaticlanguage: ‘Hasdifficulties having aconversation with others’

Group comparisons

Population sample of Norwegian primaryschool children:RD (n = 332)ADHD (n = 169)ADHD + RD (n = 121)Controls (n = 5050)

Based on parent and teacher report ofconversation skills, children with ADHD hadpoorer pragmatic ability than the controlchildren, but did not differ from those withRD. Children with combined ADHD andRD had poorer pragmatic ability than thosewith ADHD alone


Table 1. Continued.

Reference Measures and method Participants: N, age range, groups Main findings regarding pragmatic language

Humphries et al.(1994)

Teacher questionnairedeveloped by theresearchers to measurepragmatic, receptive andexpressive language

Group comparisons

Clinic-referred boys aged 6–13 years andcontrols:AP (n = 30LD (n = 33)AA (n = 32)

AP boys had significantly more teacher-ratedproblems with pragmatics than the LD and AAgroups. A total of 60% of AP boys hadpragmatic problems, especially in the area ofmaintaining conversation: poor turn-taking andindiscriminate topic changes

Ketelaars et al.(2010)

Teacher form of the CCC(Dutch translation)

Teacher form of SDQ(Dutch translation)

Correlation

Community sample of 1364 first-gradechildren (mean = age 4;11)

Hyperactivity/inattention as measured by the SDQwas strongly associated with overall pragmaticlanguage abilities (r = –0.60). Amongst childrenwith pragmatic language impairment asmeasured by the CCC, a large proportion(32.4% of girls, 56% of boys) hadhyperactivity/inattention problems

Leonard et al.(2011)

Parent form of CCC-2CPRS-R:SSSRSCorrelation and regression

Community sample of 54 children (aged9–11 years)

PL impairment was moderately correlated withboth hyperactivity (r = 0.45) and inattention (r= 0.46). PL fully mediated the relationshipbetween hyperactivity and social skills problems,and partially mediated the relationship betweeninattention and social skills problems

St. Pourcainet al. (2011)

SCDC (measure ofsocial-communicationtraits)

SDQ (measure ofhyperactive-inattentivetraits)

Latent profile analysis

Population sample of 5383 children.Multiple measures taken between 4and 17 years in a longitudinal study

Social-communication and hyperactive-inattentivetraits were strongly related over time. Themajority (82%) of children with persistenthyperactive-inattentive traits were persistentlyimpaired in social communication

Note: PL, pragmatic language; CCC, Children’s Communication Checklist; CCC-2, Children’s Communication Checklist—Revised; SCDC, Social and Communication DisordersChecklist; SDQ, Strengths and Difficulties Questionnaire; CPRS-R:S, Conners’ parent rating system revised, short version; SSRS, social skills rating system; ADHD, attention deficithyperactivity disorder; PDD-NOS, pervasive developmental disorder not otherwise specified; SLD, specific learning disability; HFA, high-functioning autism; ASD, autism spectrumdisorder; AS, Asperger’s syndrome; NC, normal controls; TD, typically developing; AP, attention problems; LD, learning disability; AA, average achievement; RD, reading disorder;and SNAP-IV, Swanson, Nolan and Pelham—IV.

children with ADHD, with the degree of impairmentintermediate between ASD groups (most impaired) andthe normal comparison groups (not impaired) (Geurtset al. 2004, Geurts and Embrechts 2008, Hellandet al. 2012a). In addition to the comparisons with ASD,there is evidence that children with ADHD have prag-matic difficulties comparable with children with readingdisorder and SLI (Helland et al. 2012b, 2012c).

Further to the studies described above, a Swedishstudy used a parent questionnaire, the Five to Fifteen, toexamine language difficulties in a sample of 76 clinic-referred school aged children with a diagnosis of ADHD(Bruce et al. 2006). Consistent with other questionnairestudies, they found that PL was highly rated as an area ofdifficulty in this sample, and half the children were alsorated as having moderate to severe language comprehen-sion problems. This result needs to be interpreted care-fully: it might suggest that many of the children had co-morbid receptive language impairment. The five itemsmeasuring language comprehension, however, appear totap pragmatic aspects of high level listening compre-hension (e.g. understanding explanations/instructions;understanding abstract concepts). Poor ratings on theseitems likely occur because of high level pragmatic diffi-culty, but could also occur because of more basic deficits

in receptive language processing. These considerationsindicate that some questionnaires may not adequatelydifferentiate PL problems from possible language pro-cessing problems, and thus may not allow clear identifi-cation of the nature of children’s difficulties.

Thus the Bruce et al. (2006) study highlights somedrawbacks of using a questionnaire to examine PL inchildren with ADHD without adequately taking intoaccount the potential contribution of co-morbid SLI(and other disorders). Indeed, most of the children in thestudy had co-morbid diagnoses such as learning disabil-ities and oppositional defiant disorder. Although ratesof SLI were not reported, 54% had been referred toa speech pathologist prior to participating in the study.Their pragmatic difficulties may be partly attributable toSLI or other co-morbid disorders rather than to ADHDalone. These considerations indicate that questionnairestudies need to be interpreted carefully. As can be seenfrom table 1, however, CCC and CCC-2 are widely usedmeasures of PL in research, and these measures mitigateagainst the potential drawbacks of questionnaires. TheCCC and CCC-2 were developed to distinguish be-tween children with primarily PL problems and thosewith language profiles suggestive of SLI (Bishop 2003,Norbury et al. 2004), and include separate subscales


to measure both pragmatic and structural aspects oflanguage.

The questionnaire studies discussed so far examinedgroup differences in PL between children with variousclinical diagnoses. In particular, several were concernedto discover whether the CCC or CCC-2 could effec-tively distinguish between children with a diagnosis ofADHD and those with various diagnoses on the autismspectrum. There is increased recognition, however,that behavioural symptoms of ADHD frequently over-lap with behavioural symptoms of ASD (St. Pourcainet al. 2011), which implies that the groups comparedin the studies may not be sharply distinct. Pragmaticimpairments may be attributable to specific behaviouralor cognitive characteristics of the children (e.g. hyperac-tivity, inattention) that cut across diagnostic categories.In order to understand how PL difficulties may be re-lated to ADHD characteristics, the next section reviewsquestionnaire studies that examined PL in relation toADHD symptoms, rather than to an overall diagnosticcategory.

Questionnaire studies of children with symptomsof ADHD

Hyperactivity and inattention are two of the key be-havioural symptoms of ADHD. There is evidence thateven in non-diagnosed children a combined measure ofhyperactivity/inattention has a strong negative relation-ship with PL abilities (Ketelaars et al. 2010, St. Pourcainet al. 2011). This suggests that the PL difficulties maybe related to behavioural features that occur to a highdegree amongst children with an ADHD diagnosis, butalso in the population more generally. The use of a com-bined measure of hyperactivity/inattention in these twostudies, however, does not allow any inferences aboutwhether hyperactivity and inattention are separately re-lated to PL difficulties.

There is a small body of inconclusive evidenceregarding separate relationships of hyperactivity andinattention with PL. Two studies suggest that atten-tion problems specifically contribute to PL difficulties(Bignell and Cain 2007, Humphries et al. 1994). Inparticular, Bignell and Cain (2007) found that childrenwith poor attention and those with poor attention andhyperactivity were impaired in PL, while those withhyperactivity only were not impaired. In contrast, onerecent study found that PL difficulty was moderatelyassociated with parent ratings of both inattention (r =0.46) and hyperactivity (r = 0.45) (Leonard et al. 2011).

The differing results with respect to hyperactivityin Bignell and Cain (2007) and Leonard et al. (2011)highlights the way in which results can be influenced bychoice of data analytic method. Bignell and Cain com-

pared PL abilities between various groups defined byteacher ratings on the ADD-H Comprehensive TeacherRating Scale (Ullman et al. 1999). The ‘high hyperactiv-ity’ group was based on a lenient criterion of scores abovethe 75th percentile on the relevant subscale. The lackof difference in PL between the ‘high hyperactivity’ and‘normal control’ groups is likely because the ‘high hy-peractivity’ group included children whose activity levelswere within the normal range. Given evidence that be-havioural features of ADHD are distributed throughoutthe population (Shaw et al. 2011), group comparisonsbased on a cut-point on a continuous measure may notbe the most appropriate way to identify whether specificADHD symptoms underlie PL difficulties. Instead, itmay be more informative to examine associations be-tween ADHD symptoms and PL ability, as in severalrecent studies (Ketelaars et al. 2010, Leonard et al. 2011,St. Pourcain et al. 2011).

Despite the different analytic methods used (groupcomparisons and association methods), and limited ev-idence regarding specific relationships with symptomsof ADHD, the questionnaire studies are consistent infinding PL difficulties in children with ADHD traits.It is worth noting however that while the evidence in-dicates that children with ADHD traits do experiencePL difficulty, the reverse is not necessarily the case: chil-dren with PL difficulty may not all have ADHD traits.St. Pourcain et al. (2011) found that almost all (82%)of the children with persistent hyperactivity/inattentionhad social-communication difficulties, but only 32%of the children with persistent social-communicationdifficulties had persistent hyperactivity/inattention (an-other 39% had somewhat elevated levels of hyperac-tivity/inattention though). In a similar vein, Donnoet al. (2010) found PL deficits in a group of disrup-tive primary school children, but this group did nothave poorer attention skills than comparison children,and were not more likely to meet research criteria forADHD. These findings indicate that PL difficultiescan occur in the absence of attention or hyperactivityproblems.

In summary, the questionnaire studies provide con-sistent evidence that children with a diagnosis ofADHD, or symptoms of ADHD, are likely to ex-perience PL difficulties. Aspects of PL that seemmost impaired are inappropriate initiation, conversa-tional turn-taking, and coherence. Perhaps not sur-prisingly, several studies found that PL difficulties arenot as severe in ADHD as in ASDs (Geurts et al.2004, Geurts and Embrechts 2008, Helland et al.2012a). Unfortunately, questionnaire studies do notallow the conclusion that the symptoms of hyperac-tivity and inattention separately underlie PL difficul-ties, and none of the questionnaire studies examinedimpulsivity.


Table 2. Observational and experimental studies of pragmatic aspects of communication in children with ADHD, ADD orhyperactivity

Findings: experimental group versus comparisonReferences Method and measures Participants groups

Bignell and Cain(2007) (Study 1)

Comprehension offigurative language:children selected picturesto illustrate the meaningof ambiguous phrases

Community sample of childrendifferentiated by teacher ratings ofpoor attention and/or hyperactivity,separate control groups (7–11 years):Hyperactive (n = 16)Poor attention (n = 19)Hyperactive/poor attention (n = 14)Controls (n = 18, 19, 17)

All three experimental groups were impaired incomprehension of figurative language: theyfrequently selected a literal interpretationeven when context supported a figurativeinterpretation

Clark et al. (1988) Structured peer interactiontasks

Observational ratings ofverbal and non-verbalinteractions and taskorientation

Diagnosed and NC boys (7–9 years):ADD-H (n = 10)NC (n = 30)

Mixed dyads (ADD-H and NC) showed lesssophisticated conversation skills and were lessable to maintain reciprocal dialogue over timethan control dyads (NC and NC). Mixeddyads showed less cooperation and jointactivity to meet task goals

Cohen et al.(2000)

Administered the PP 166 clinic-referred children (7–14 years):ADHD (n = 105)OPD (n = 61)

ADHD group did not differ from other clinicalgroups on pragmatic language. Children withADHD + LI + RD showed worse pragmaticskills than those with ADHD + LI

Kim and Kaiser(2000)

Standardized TOPL;unstructuredconversation with adult,coded according to thePP

Diagnosed children and TD controls(6–8 years):ADHD (n = 11)TD (n = 11)

Groups did not differ on pragmatic knowledgeas measured by TOPL. ADHD group showedmore inappropriate pragmatic behaviours inconversation, particularly lack of response topartner and interruptions

King and Young(1981)

Structured peercommunication task:‘Space Flight’ game

Observational ratings ofcommunication contentand quality

Teacher nominated hyperactive boys (n= 18) and active but normal boys (n= 18) aged 7–11 years

On most aspects of communication thehyperactive group was able to adapt to roledemands of message receiver versus messagesender. The hyperactive group showed slightdifficulty relative to control boys: it tended to‘disagree’ and ‘give directions’ equally often inboth roles

Landau and Milich(1988)

Unstructured peercommunication task:‘TV Talk Show’ game


Community sample of boys differentiatedby teacher ratings of inattention andover-activity (3rd–6th Grades):ADD (n = 17)Controls (n = 53)

ADD group was less able to adapt its verbalcommunication according to differing roledemands of ‘host’ and ‘guest’ of a televisiontalk show, e.g. offered the same number of‘answers’ in both roles

Whalen et al.(1979)

Structured peercommunication task:‘Space Flight’ game


Diagnosed and NC boys (7–11 years):Hyperactive (n = 23)NC (n = 39)

Irrespective of medication status, hyperactivegroup was less able to adapt its verbalcommunication according to differing roledemands of ‘Mission Control’ (messagesender) and ‘Astronaut’ (message receiver).Fewer appropriate responses to verbal cuesfrom partner. In ‘Astronaut’ role, frequentlydisagreed with partner despite no objectivebasis for disagreement

Zentall et al.(1983)

Referential communicationtask: children listened toinstructions andresponded

Observations of verbalbehaviour during tasksand transitions betweentasks

Community sample of boysdifferentiated by teacher ratings ofhyperactivity (3–7 years):Hyperactive (n = 13)Control (n = 13)

Hyperactive boys talked more and were moreverbally impulsive than NC during listeningtasks and transitions between tasks.Hyperactive boys’ speech was less task-related

Zentall (1988) Storytelling tasks andnon-verbal tasks

Observations of verbalbehaviour during tasksand transitions betweentasks

Community sample of childrendifferentiated by teacher ratings ofhyperactivity (7–11 years):Hyperactive (n = 22)Control (n = 22)

Hyperactive children were more spontaneouslytalkative than controls during transitions andnon-verbal tasks (non-elicited conditions)and less talkative when asked to tell stories(elicited condition)

Note: ADD, attention deficit disordered; ADD-H, attention deficit disordered, hyperactive; ADHD, attention deficit hyperactivity disorder; OPD, other psychiatric disorder; LI,language impairment; RD, reading disability; TD, typically developing; NC, normal controls; TOPL, Test of Pragmatic Language; and PP, Pragmatics Protocol.


Observational and experimental studiesof pragmatic aspects of communication

Nine studies, mostly from the 1980s, examined social-communication abilities directly. These are summarizedin table 2. Although these studies did not use the term‘pragmatic language’, they are relevant to the reviewbecause they focus on the quality of verbal communi-cation in children with behavioural features of ADHD.These studies used observational ratings of children’scommunication taken from interactive tasks with peersor adults, and complement the questionnaire studies inproviding more detailed information about the natureof PL difficulties in ADHD. The general finding wasthat children with features of ADHD have difficultyadapting their communication strategies appropriatelyaccording to situational demands.

Several studies examined peer communication inchildren with hyperactivity/inattention (Clark et al.1988, King and Young 1981, Landau and Milich 1988,Whalen et al. 1979), primarily motivated by the fre-quent occurrence of poor peer relations amongst chil-dren with ADHD (Whalen and Henker 1985, Whalenet al. 1979). These studies involved cooperative com-munication tasks with peers, during which boys aged7–11 years worked in pairs that were either mixed (onehyperactive/inattentive boy and a comparison boy) orcontrol (two comparison boys). The tasks were pre-sented as games, including a Space Flight game withroles of astronaut and mission control (King and Young1981, Whalen et al. 1979) and a television talk showgame with roles of host and guest (Landau Landau andMilich 1988). The main finding of these studies was thatboys with ADHD traits were significantly less able thantypically developing boys to adapt their communicationaccording to task demands: they tended to make taskirrelevant comments, to argue and to interrupt whilein listening roles, and they had difficulty maintainingappropriate communication over time in order to meetjoint goals.

Other studies examined children’s communicationpatterns with an adult (Cohen et al. 2000, Kim andKaiser 2000, Zentall et al. 1983, Zentall 1988). Thesestudies are largely consistent with the peer communi-cation studies, indicating that children with ADHDexhibit excessive verbalizations during times when quietlistening would be expected and tend to interrupt theirconversational partner. In contrast to the relatively largeamounts of spontaneous speech, Zentall (1988) foundthat 7–11-year-old hyperactive boys produced markedlyless elicited speech than comparison boys when askedto tell stories. Zentall concluded that the hyperactiveboys had language production deficiencies under con-ditions when they were required to organize and plantheir speech for a specific purpose. The requirement toorganize speech for a specific purpose is more likely to

occur when speech is elicited by another person—suchas when a child is asked to answer a question, provide in-formation, or tell a story—as opposed to spontaneouslyproduced speech.

Thus the observational studies of peer and adultcommunication patterns are consistent in finding thatchildren with ADHD traits have difficulty inhibitingexcessive verbalizations in certain conditions, includingwhen they are expected to take listening roles. This maymanifest as frequent interruptions, spontaneous com-ments that are unrelated to the task, and difficulty withconversational turn-taking. At the same time, there isevidence that children with ADHD traits sometimeshave difficulty producing appropriate purposeful speechin conditions when this is expected, including whenspeech is actively elicited by a conversational partner,such as telling stories (Zentall 1988), taking an activerole as ‘host’ in the television talk show game (Landauand Milich 1988) and responding to questions fromothers (Kim and Kaiser 2000).

Despite the consistent evidence that children withADHD show inappropriate PL use in various contexts,two studies indicate that children with ADHD traitsdo have knowledge of appropriate PL use. Kim andKaiser (2000) found that 6–8-year-old children withADHD demonstrated adequate pragmatic knowledgeas measured by the individually administered Test ofPragmatic Language (Phelps-Terasaki and Phelps-Gunn1992) despite producing inappropriate pragmatic be-haviours during an unstructured conversation with anadult. Similarly, Bignell and Cain (2007, Study 1) foundthat 7–11-year-old children with poor attention and hy-peractivity had adequate knowledge of figurative mean-ings of ambiguous expressions despite their response biasfor inappropriate literal interpretations in context. Thispattern of results indicates that children with featuresof ADHD may have difficulty applying their pragmaticknowledge appropriately in context, suggesting a per-formance deficit rather than a knowledge deficit. It isconsistent with findings from the peer communicationstudies that the hyperactive/inattentive boys were some-times able to adapt their communication appropriately,suggesting they possess appropriate peer communica-tion skills but may not deploy their skills consistently(King and Young 1981). As noted by several researchers,structured tests of pragmatic knowledge do not neces-sarily provide an indication of pragmatic performance incontext, which may be more validly measured with nat-uralistic observations and questionnaires (Adams 2002,Russell and Grizzle 2008).

Studies of high-level language abilities withimplications for pragmatic language (PL)

The nine studies summarized in table 3 documenthigh-level difficulties with language comprehension and


Table 3. Experimental studies of higher-level language abilities in children with ADHD, with implications for pragmatic aspects oflanguage

Findings: experimental group versus comparisonReference Method and measures Participants groups

Engelhardt et al.(2009)

Experimental sentenceproduction task: participantswere presented with twopictures and a verb and askedto form a sentence

Diagnosed adolescents and adults,controls (aged 13–35 years):ADHD (n = 108)NC (n = 87)

Children with ADHD (combined subtype) weremore likely than controls to produce anungrammatical sentence. Results suggest theystarted to speak before formulating a plan for thesentence, indicating a deficit in response inhibition

Mathers (2006) Samples of elicited spoken andwritten language in variousgenres (recount, procedural,narrative)

Children aged 8–12 years:ADHD (n = 11)NC (n = 11)

ADHD group did not differ from the comparisongroup on number of utterances, number of wordsor pauses, or length of utterances. ADHD groupshowed more tangential and abandonedutterances, and poorer organization of its spokenand written texts

McInnes et al.(2003)

Listening comprehension task;working memory tasks;standardized tests ofexpressive and receptivelanguage abilities

Diagnosed boys and normalcontrols (9–12 years):ADHD (n = 21)ADHD + LI (n = 18)LI (n = 19)NC (n = 19)

Children with ADHD showed subtle, higher-levellistening comprehension deficits, despite adequatelanguage abilities on standardized tests. They wereimpaired in comprehension of inferences andmonitoring instructions from spoken passages.Inference comprehension was correlated withworking memory (r = 0.42), ADHD grouppoorer than NC on working memory tasks

Papaeliou et al.(2012)

Children listened to a recordingof a children’s folktale andanswered questions thatassessed their comprehensionof story elements

Children aged 6–11 years:ADHD (n = 25)TD (n = 25)

ADHD group recalled less factual information fromthe story and was less aware of the thematicimportance of the story information that wasrecalled. Story recall was positively correlated withverbal working memory, and the ADHD groupshowed poorer working memory than thecomparison group

Purvis andTannock(1997)

Story retelling task andstandardized tests ofexpressive and receptivesemantic language abilities

Diagnosed children and normalcontrols (7–11 years):ADHD (n = 14)ADHD + RD (n = 14)RD (n = 8)NC (n = 14)

Irrespective of RD status, children with ADHDexhibited difficulties organizing andself-monitoring their verbal productions in thestory retelling task. Pure ADHD group was notimpaired in expressive and receptive semanticlanguage abilities, or story comprehension. Thusdeficits specific to ADHD group reflect difficultieswith language use, i.e. pragmatics

Redmond (2004) Conversation sample duringfree play with the researcher

Diagnosed sample (5–8 years):ADHD (n = 10)SLI (n = 10)TD (n = 13)

Compared with TD and SLI groups, ADHD groupwas slightly more dysfluent in its utteranceformulation, including more pauses, repetitions,revisions and abandoned utterances. ADHDgroup did not differ from TD group on any otherlinguistic measure

Rumpf et al.(2012)

Story elicitation task: childrenwere asked to tell the storydepicted in a picture bookabout frogs that fly on waterlilies. The task is from theADOS

Groups of children aged 8–12years:AS (n = 11, all boys)ADHD (n = 9, one girl)HC (n = 11, one girl)

AS and ADHD groups produced significantlyshorter narratives than the HC group, and morefrequently failed to convey the main aspects of thestory. The AS and ADHD groups could not bedistinguished from each other on these measures.The AS group but not the ADHD group madeless frequent references to mental states. Nodifferences between groups on cohesion measures

Tannock et al.(1993)

Story retelling task: childrenlistened to short stories thenretold them

Boys aged 7–11 years:ADHD (n = 30)NC (n = 30)

Groups did not differ in comprehension of stories,but did differ in story retelling task. Stories ofADHD group were less informative, lessorganized, less cohesive and contained moreinaccuracies

Wassenberg et al.(2010)

Participants completed twoneuropsychological tests ofcomplex sentencecomprehension. Responseswere made verbally or bypointing

Diagnosed children (aged 8–11years) and adolescents (aged12–16 years), age-matchedcontrols:ADHD (n = 30)Controls (n = 30)

ADHD group performed more slowly oncomprehension tasks, but did not differ fromcontrols in accuracy

Note: ADHD, attention deficit hyperactivity disorder; RD, reading disability; SLI, specific language impairment; NC, normal comparison; HC, healthy controls; AS, Asperger’ssyndrome; and ADOS, Autism Diagnostic Observation Schedule.


production. High-level language refers to complex lan-guage skills that involve interpretation and comprehen-sion beyond the sentence level and the use of strategiessuch as organizing and monitoring of responses (Chen-ery et al. 2002, Cook et al. 2004). Even when struc-tural language abilities are normal, people can experi-ence subtle, high-level language difficulties. Examplesinclude: problems understanding lengthy instructions,identifying the main theme in a story, inferring figura-tive meanings from context, and producing coherent,well-organized speech for a particular purpose. Thesehigh-level language difficulties can be considered as-pects of PL in that understanding subtle meanings andproducing coherent verbal messages for others is cen-tral to appropriate language use in interpersonal con-texts. The researchers interpret deficits in these capac-ities as PL difficulties rather than specific impairmentin structural aspects of language, in part because manyof the children in this group of studies had normalscores on standard measures of receptive and expres-sive language abilities (Mathers 2006, McInnes et al.2003, Papaeliou et al. 2012, Purvis and Tannock1997).

Findings regarding high level listening comprehen-sion in children with ADHD are mixed. Some studiesreport deficits in aspects of comprehension, includingspeed of comprehension (Wassenberg et al. 2010), un-derstanding inferences (McInnes et al. 2003) and recog-nizing the thematic importance of elements in a story(Papaeliou et al. 2012). In contrast, two earlier stud-ies found that the ability to understand and identifythe main ideas in stories is not impaired (Purvis andTannock 1997, Tannock et al. 1993). The differingfindings suggest variability in listening comprehensionabilities amongst children with ADHD, but may alsobe due to differences in tasks demands. For instance,Wassenberg et al. (2010) found that the ADHD groupwas not impaired in listening accuracy but was slower inproducing responses, which they interpret as impairedspeed of comprehension although it is also consistentwith impaired speed of producing a response.

Complementary to the studies on listening compre-hension, studies consistently reveal a range of languageproduction difficulties in children with ADHD. Thesedifficulties include a tendency to produce ungram-matical sentences under certain conditions (Engelhardtet al. 2009), a relatively high rate of speech dysfluen-cies in conversation and in oral texts (Mathers 2006,Redmond 2004) and lack of coherence and accuracywhen retelling narratives (Purvis and Tannock 1997,Tannock et al. 1993, Rumpf et al. 2012). The studieson speech dysfluencies did not report on key aspects ofPL, such as children’s responsiveness to the conversa-tional partner, or the coherence of their speech from theperspective of a listener. Nonetheless the speech features

reported—abandoned utterances, repetitions, pauses—are consistent with Engelhardt et al.’s (2009) findingson sentence production and suggest that children withADHD tend to speak before they have planned what tosay. Relatedly, Tannock et al. (1993) and Tannock andSchachar (1996) propose that the poorly retold storiesof children with ADHD reflect problems with planningand monitoring their verbal productions. Such prob-lems detract from effective PL use, including failures ofcohesion and failure to adapt verbal production to theneeds of a listener (Prutting and Kirchner 1987).

Several explanations have been proposed for thelanguage comprehension and production difficulties ofchildren with ADHD. Regarding language production,Engelhardt et al. (2009) propose that deficits in responseinhibition may lead children to speak before they haveplanned what to say. In contrast, Purvis and Tannock(1997) suggest that monitoring of information requiredfor narrative production requires a range of executivefunctions, including working memory and control ofattention. It is likely that different aspects of execu-tive function may be involved in the different languageproduction tasks, but unfortunately the language pro-duction studies reported here did not measure executivefunctions. Deficits in verbal working memory have beenproposed to underlie listening comprehension prob-lems. Two studies found that listening comprehensiondeficits were related to working memory deficits in chil-dren with ADHD, consistent with theoretical concep-tions of language comprehension in which explicit andimplied information is held in memory and continu-ally modified as new information is processed (McInneset al. 2003, Papaeliou et al. 2012).

In sum, the studies of higher-level language abili-ties in children with ADHD reveal deficits in languageproduction both at the sentence level and the level ofextended narrative. These results are consistent withthose of Zentall et al. (1983) and Zentall (1988) infinding production difficulties under conditions whenspeech is elicited from a conversational partner as op-posed to spontaneously produced speech. These pro-duction deficits occur even when basic language skillsin semantics, phonology and syntax are normal. Theevidence regarding listening comprehension in childrenwith ADHD is more mixed. Some studies found ev-idence of subtle deficits in comprehending inferencesand recognizing the importance of story elements, whileother studies found no problems in story comprehen-sion. The mixed results regarding listening comprehen-sion suggests variability in this aspect of PL, consistentwith findings previously described that children withADHD symptoms do understand figurative meaningsof ambiguous expressions despite an initial bias towardsinappropriate literal interpretations (Bignell and Cain2007).


Conclusions

The purpose of this review was to integrate empiricalfindings on the PL abilities of children with features ofADHD. Thirty empirical studies were identified acrossthree relatively distinct lines of research: (1) question-naire studies of PL abilities, most of which made use ofthe CCC or CCC-2; (2) observational and experimen-tal studies of children’s communication patterns withpeers or adults; and (3) studies of children’s higher-levellanguage comprehension and production abilities. Thereview addressed the extent and nature of PL difficultiesin children with ADHD or symptoms of ADHD.

Extent and nature of PL difficulties in childrenwith features of ADHD

Evidence from the three lines of research consistentlyshows that children with features of ADHD have moredifficulty with PL than do typical comparison children.In non-diagnosed children, measures of combined hy-peractivity and inattention were found to be stronglyassociated with PL difficulties. Across all three lines ofresearch it can be concluded that children with ADHDor symptoms of ADHD exhibit PL difficulties primarilyin the following areas:

� Excessive talking, including during times whenthe situation calls for listening.

� Difficulty producing coherent, organized and flu-ent speech for specific purposes, especially underconditions when speech is elicited as opposed tospontaneous.

� Difficulty adopting appropriate listener andspeaker roles, including a tendency to dominateconversations and not respond adequately to ver-bal cues from conversational partners.

� Some indication of possible difficulty with higher-level language comprehension, particularly for in-ferences and story elements.

Although all the reviewed studies found evidence of PLdeficits in children with ADHD, it is important to noteevidence that children with ADHD sometimes demon-strate adequate PL abilities (Bignell and Cain 2007, Kimand Kaiser 2000, King and Young 1981). This suggeststhat children with ADHD may possess adequate knowl-edge of some aspects of PL, but struggle to apply theirknowledge consistently in context. This would indicatethat their deficits might lie more in pragmatic perfor-mance than in pragmatic knowledge per se.

Relatedly, several questionnaire studies found thatchildren with ADHD are not as impaired in PL as chil-dren with ASD (Geurts et al. 2004, Geurts and Em-brechts 2008, Helland et al. 2012a). In particular, chil-

dren with ADHD were less impaired than those withASD on stereotyped language and non-verbal commu-nication. Furthermore, this review does not indicate anyparticular difficulties amongst children with ADHD inpedantic speech or overly literal use of language. Someresearchers have interpreted the PL difficulties foundin children with ADHD as indicating continuity ofsymptoms between ADHD and ASD (Bishop and Baird2001, St. Pourcain et al. 2011). While similarity betweenADHD and ASD in some features of PL difficulty is ap-parent, this review highlights the multidimensional na-ture of PL, and indicates that the PL profile of ADHDmay differ in some respects from that of ASD.

Directions for future research

As Camarata and Gibson (1999) noted some time ago,specific relationships between behavioural features ofADHD and aspects of PL need to be identified in or-der to understand better why PL difficulties are com-mon amongst children with ADHD. At this time thereis insufficient evidence to conclude that PL difficultiesare related to specific behavioural features of ADHD.Most studies examined PL in relation to a combinedmeasure of hyperactivity/inattention, or used diagnosedchildren without specifying to which diagnostic subtypethey belonged. None of the identified studies measuredimpulsivity. The lack of evidence regarding specific re-lationships is perhaps understandable given that ‘prag-matic language’ and ‘ADHD’ are both multidimensionalconcepts that have been subject to changing definitionsand, at least in the case of ADHD, changing diagnosticcriteria over the period covered by the review. It willbe informative for future research to identify whetherprofiles of PL difficulty in ADHD are specifically asso-ciated with symptoms of hyperactivity, inattention andimpulsivity.

Relatedly, further research is needed to examinewhether deficits in executive function can account forPL difficulty in children with features of ADHD. Sev-eral of the studies reviewed here noted that the PL dif-ficulties are consistent with deficits in executive func-tions (Engelhardt et al. 2009, Purvis and Tannock1997, Tannock et al. 1993). Only two of the studiesmeasured aspects of executive function, however, withboth finding positive correlations between higher-levellistening comprehension and verbal working memory(McInnes et al. 2003, Papaeliou et al. 2012). Possi-ble relationships between PL, behavioural symptoms ofADHD and executive functioning can be identified onlywhen all these factors are studied together. Possible hy-potheses that could be empirically investigated include:(1) deficits in response inhibition will be associatedwith excessive talking, as indicated by conversationaldominance and frequent interruptions; and (2) deficits


in working memory and sustained attention will be asso-ciated with disorganized, confusing speech, as indicatedby lack continuity and cohesive links between individualutterances.

Implications and summary

The PL difficulties in children with features of ADHDare likely to have a negative influence on their socialand academic functioning. The studies of children’s peercommunication patterns emphasize that over time thecommunication difficulties of hyperactive children maylead peers to withdraw from social interaction with them(Clark et al. 1988, Landau and Milich 1988). Indeed,Leonard et al. (2011) found that PL difficulties fully me-diated the relationship between hyperactivity and socialskills problems, and partially mediated the relationshipbetween inattention and social skills problems.

While many of the studies reviewed here reportedon language use in experimental tasks, they have clearimplications for children’s language use more generally.Difficulty with comprehending and drawing inferencesfrom other peoples’ verbal messages in a timely man-ner would impair a child’s ability to understand hints,jokes, lengthy instructions and conversations. Likewise,dysfluent speech with tangential utterances, and disor-ganized speech that fails to take the listener’s perspectiveinto account, would impair a child’s ability to maintainconversational rapport and use language to achieve jointgoals with other people. These PL difficulties would beparticularly problematic in school and social contexts inwhich verbal messages are often delivered rapidly withan expectation of fast responses. As such, PL shouldbe assessed as part of clinical assessment for ADHDand targeted for treatment where needed. Understand-ing the behavioural and cognitive underpinnings of PLdifficulty in ADHD should lead to intervention pro-grammes that are better tailored to the needs of thispopulation.

Acknowledgements

The authors would like to thank two anonymous reviewers for theirconstructive comments and suggestions for improving this review.Declaration of interest: The authors report no conflicts of interest.The authors alone are responsible for the content and writing of thepaper.

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