pragmatic language impairment: case studies of social and pragmatic language therapy

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2005 21: 227Child Language Teaching and TherapyCatherine Adams, Janet Baxendale, Julian Lloyd and Catherine Aldred

therapyPragmatic language impairment: case studies of social and pragmatic language

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Child Language Teaching and Therapy 21,3 (2005); pp. 227-250

Pragmatic language impairment: casestudies of social and pragmatic languagetherapyCatherine Adams, Janet Baxendale, Julian Lloyd and Catherine AldredUniversity of Manchester, Manchester, UK

Abstract

The current position on speech and language intervention for children whohave pragmatic language impairment (PLI) is limited by a lack ofevidence tosupport practice. Two intervention outcome case studies ofchildren with PLI,aimed at establishing efficacy, are presented in this paper Standardizedlanguage tests and conversational sampling were used to assess the childrenpre- and post-therapy. Each child received eight weeks of intervention, threetimes a week, from a specialist speech and language therapist. This experi-mental treatment, which was funded as part of a research project, targetedsocial adaptation skills of the child and adults in his communicationenvironment, in addition to work on communication acts, conversation andnarrative skills andfacilitating understanding ofsocial inference. One child,with isolated social andpragmatic difficulties, showed measured and reportedimprovements in conversational skills. The second child, who has additionallanguage disorder, showed changes in language processing skills but nochanges in pragmatic abilities. The implications for choosing interventions,for the training of practitioners and questions for further research arediscussed. The therapy resources used in intervention are listed.

Introduction

Children with pragmatic language impairments (PLI) represent a significantproportion of the speech and language therapist's caseload both within andoutside of educational settings. These children share characteristics withgroups such as autism and specific language impairment and are thought to

Address for correspondence: Dr Catherine Adams, Human Communication and Deafness Group, Universityof Manchester, Oxford Road, Manchester M13 9PL, UK. E-mail: [email protected]

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228 Child Language Teaching and Therapy

represent an intermediate group between these two conditions (Bishop, 2000).Although children with PLI can present in the early years with significantlanguage delay, often these difficulties seem, at least superficially, to beovercome by the school years and children may be fluent with seeminglynormal use of syntax (Rapin and Allen, 1998; Botting and Conti-Ramsden,1999). Formulation problems may remain at an above sentence level, however,with considerable lack of organization of discourse and narrative despitesurface fluency (Bishop and Adams, 1989; Botting, 2002; Norbury andBishop, 2003), substantial problems with understanding discourse, over-literaluse of language, impaired understanding of social inference (Leinonen andLetts, 1997), limitations in social use of language (Bishop, 2000; Bishop et al.,2000) and with aspects of social cognition (Shields et al., 1996) remain.Added to this, in some individuals, is a tendency to talk about personalpreoccupations, intense questioning style with repetition and some stereotypedspeech (Bishop and Adams, 1989). These features are similar to those ofchildren from the autistic spectrum and tend to persist in PLI, creating animbalance between limited social communication and relatively good formallinguistic abilities which then compounds personal and educational progress.

PLI research to date has concentrated largely on the nature of the underlyingdisorder (Bishop, 2000; Shields et al., 1996) and on the characterization ofPLI in order that diagnostic criteria might be established (Adams and Bishop,1989; Bishop and Adams, 1989). Relatively little research has focused onappropriate intervention strategies or on the efficacy of current managementfor children with PLI. Certainly no intervention research has been carried outwhich reflects the heterogeneous character of the group and the way in whichthis impinges on research methods in therapy studies.A systematic review of intervention for developmental language disorders

failed to locate any randomized control trials or smaller scale group studiesthat addressed pragmatic language intervention (Law et al., 2003). The PLIintervention research base contains cohort studies which have considered verybroadly defined groups of language impaired children (not specificallychildren with PLI) or which attempted to evaluate specific service provisionmodels (Bedrosian and Willis, 1987; Camarata and Nelson, 1992) applied tobroad populations of children with communication impairments. Aspects ofintervention aimed at ameliorating language pragmatics have been consideredwith related populations such as children with learning disabilities(Richardson and Klecan-Aker, 2000) and have generally found positiveresults. Single case studies have provided valuable infornmation regardingprogress with individualized therapy for children with PLI (Conti-Ramsdenand Gunn, 1986; Letts and Reid, 1994; Willcox and Mogford-Bevan, 1995;



Pragmatic language impairment 229

Adams, 2001; Olswang et al., 2001). All these papers point towards the factthat the communication skills of children with PLI and associated conditionsprobably benefit from speech and language therapy and indicate that specificimprovements in language pragmatic skills, which directly impinge upon thechild's quality of communication, might be possible.

Current practice in the UK is guided by models that combine three majordevelopmental influences on the broad domain of pragmatics: social, cognitiveand linguistic. This model was propounded for clinicians in the seminal workof Prutting and Kirchner (1987) and McTear and Conti-Ramsden (1991), andwas developed in an accessible form for practitioners by Leinonen et al.,(2000). The model encouraged practitioners to view pragmatics as a broad-based set of communication behaviours, encompassing inference and socialparticipation as well as the more formal linguistic devices seen in conversa-tional exchanges and narratives. The position taken in this paper is that socialcommunication development is dependent on integrity and synergy amongstemerging processes in the child.

Aspects of socialcommunication Synergy amongst these developmental factorsSocial interaction Development of social interaction, empathy and

attachmentSocial cognition Development of shared and mutual knowledgeLanguage pragmatics* Development of formal, pragmatic devices

(some specific to one language/culture)Language processing Development of formal, language specific

syntactic, semantic and phonological processing

*The term language pragmatics is adopted in this study to include all aspects ofthe pragmatics of spoken communication EXCEPT those to do with nonverbalcommunication or paralinguistic devices.

Despite the lack of an evidence base, a range of therapeutic materials isreadily available for use in pragmatics therapy. Many published resourcesfocus on developing formal linguistic aspects of pragmatic instruction such asuse of register and speech acts, which, while valuable, have restrictedapplication for some of the more able children with PLI. Practitioners,being aware of these limitations, have resourcefully employed techniquesand strategies used with related groups [e.g., Gray's social stories (1998)] totackle aspects of social cognition. There is nevertheless, some consensus thattherapy is resource- rather than principle-driven, due to the research vacuum.Practitioners rely on judgement and experience to select an interventionprogramme. There is little or no existing guidance to support these decisions.There is certainly no significant evidence for them.




As a preliminary step in investigating the utility of a principled approach tointervention, two case studies are presented which investigate the outcomes ofsocial/pragmatic therapy in facilitating communication in children with PLI.We were interested to see if there would be specific effects on social interactionand language pragmatics skills in the form of changes in conversationalparticipation or if the intervention showed more general effects of improvinglanguage processing skills as well as pragmatic ability. Direct languageprocessing work on syntax, semantics and comprehension was not includedin the intervention. Two case studies are presented with differing initialprofiles but the same diagnosis. One child showed normal language processingskills but abnormal social communication, the other had significant languageprocessing deficits and abnormal social communication.

Method

The two children described in this paper participated in a larger study ofoutcome measures of language interventions (Adams et al., in press). In thisstudy children received an intensive period of individualized speech andlanguage therapy solely targeted at pragmatics and social interaction. Eachchild received eight weeks of intervention, for 60 minutes, three times a week,from a specialist speech and language therapist. Neither child was currentlyreceiving speech and language therapy. Project therapy sessions were carriedout in lesson time in a room adjacent to the main classroom. Language testsand conversational sampling were used to assess the children pre- and post-therapy.

The basic assessment battery used included widely available standardizedtests: a measure of receptive vocabulary - The British Picture VocabularyScales (BPVS) (Dunn et al., 1997); a measure of sentence comprehension -

The Testfor Comprehension ofGrammar (TROG) (Bishop, 1983); a measureof nonverbal performance - Raven's Progressive Matrices (1976); a measureof expressive naming skills - The Naming subtest of the Assessment ofComprehension and Expression (ACE 6-11) (Adams et al., 2001). In addition,the Children 's Communication Checklist (CCC) (Bishop, 1998) was used withteachers in order to ascertain whether children had communication impair-ments of a pragmatic nature even when scores on language tests fall within thenormal range (scores below 132 on CCC). The Autism Diagnostic Interview(ADI) (Lord et al., 1994) was used to establish the social, communicationand behavioural development history of all participants. The ADI is aninvestigator-based parent interview from which responses are summed




across domains to derive an autism 'score'. The reciprocal social, communi-cation and repetitive behaviours and stereotyped patterns domains were scoredand summed. Importantly, it was therefore established that neither of thesechildren fitted diagnostic criteria for autism as defined by ADI.

The major additional assessment was an analysis of conversational interac-tion, the Analysis of Language Impaired Children's Conversation (ALICC)(for information see http://www.psych.ox.ac.uk/oscci/dbhtml/). Using thisanalysis and conversational indices developed in previous work (Bishop et al.,2000; Adams et al., 2002), spontaneous conversational samples were audio-taped discussing a topic presented in a picture e.g., a birthday party, a bonfire,a holiday trip, followed by a reduction in therapist conversational structureallowing the child to spontaneously expand into a natural conversationaldialogue. All samples were then subject to ALICC analysis. The analysis ofconversational data (up to 10 minutes of interaction) takes generally two hoursto transcribe and one hour to code by a trained coder.

Conversational indices were calculated for sets of four pre- and three post-therapy conversations. Mean indices for the two conditions were comparedwith indices derived from a control group of 10 children (mean age = 9;8years) with normal language development. Control indices were averagedacross two conversation analyses per subject. These are not treated as normsbut as points of reference for intervention planning where there was a cleardiscrepancy between individual and group performance (for further details ofthe control group performance see Adams and Lloyd, 2005). The ALICCanalysis permits the assessor to profile the conversational performance of bothinterlocutors. In this study, child indices only were derived with respect toconversational dominance (CD), loquacity (Loq) that is, the tendency to beverbose and responsiveness (Resp), the number of verbal responses to adultsolicitations, in addition to any identifiable problems with response quality orpragmatic devices or quality.

First, findings from ALICC conversations were used as an interventionplanning tool by qualitative inspection for conversational competence andfluency. Secondly, reciprocity of conversational turns, topic initiation andmaintenance were observed with particular reference to repetitive introductionof themes not relating to a previous shared topic. The degree of socialadaptation of nonverbal and verbal skills (including physical proximity, eye-gaze, and facial expression, and orientation, use of gesture, voice volume andintonation to the conversational partner) were observed.ALICC indices were employed as an outcome repeated measure by visual

inspection and any quantitative changes in an index were compared toestimates of natural variation obtained in a previous study (Adams and




Lloyd, 2005). Additional repeated outcome measures were the ACE InferentialComprehension and Narrative Propositions subtests (Adams et al., 2001) andthe CELF-R Sentence Recall and Formulating Sentences subtests (Semel etal., 2000).

Rationale of therapy

The intervention framework chosen was one of combined social adaptationand language pragmatics work. In this framework, intervention concentrateson optimizing social interaction and social cognition as a means of improvingthe child's ability to adapt communication skills to interlocutors and to socialsituations. Equally, intervention attempts to optimize adaptation of theinterlocutor to communication with the child. In addition, elements oflanguage pragmatics work are included to provide the building blocks ofsuccessful social interactions. Intervention therefore consisted of directwork with the child on formal pragmatic skills and employing training inadaptation of communication for the child those who live and interact withthe child (Gray, 1998). The intervention emphasises the importance ofthe verbal scaffolding provided for the child within the home and schoolcontext.

Intervention started with detailed observation of language pragmatic skillsusing conversation (ALICC) and social assessments (ADI) in conjunction withstandardized language tests in order to map information into the interventionframework. Planning of intervention took into account individual childcompetencies and impairments. Intensive intervention targeted individualskills in these aspects of language pragmatics. Both cases showed significantdifficulty with social interaction and social cognition which impinged uponcommunication skills. It should be noted that language processing therapy(e.g., syntactic or semantic work) was not the focus of direct intervention foreither child, though there would be justification for it at some stage for child B.Therapy for both children was planned on an individual basis and reflectedcurrent practice, i.e., building on strengths in communication throughexercises and games in interpersonal communication and by developingstrategies to promote more effective communication with others in thechild's environment. Observing the child in a range of different socialcontexts was central to the intervention, each child presented differently indifferent contexts according to the degree of structure, social andlanguage demands. Published resources used in this study are listed in theAppendix.




Principal aspects of the intervention framework

1) Communication adaptationa) Establish developmental readiness for social and language demands.

Social and language demands which exceeded the child's developmentalcompetencies and readiness may result in greater impairment in prag-matic functioning. Contributory elements in the cycle of avoidance andcommunication failure need to be identified and addressed.

b) Establish a highly adapted communication environment. Children withPLI may elicit a more didactic teaching style of interaction from adultsas a result of limited initiation, lack of reciprocal responsiveness ormisunderstanding of the degree of language competence present inrelatively fluent children. Intervention aimed to adapt parent and teacherinteraction, increasing the child's experience of social responses whichwere compatible with their developmental abilities and languagecompetencies.

c) Establish adaptation of the curriculum. This focused on making theexpectations and demands placed on the child by the curriculumcompatible with the child's developmental communication competen-cies. The language demands in the classroom were adapted, typically byhaving an assistant to translate language into short meaningful utter-ances with visual demonstration. All written language was carefullyselected to be commensurate with the child's assessed level of spokenlanguage comprehension. Classroom assistants were trained to imple-ment the individual intervention strategies and support generalisationinto the classroom.

d) Establish monitoring of responses. Adults in the child's environmentwere advised how to monitor responses to the child, focusing onproviding contingent conversation examples, to provide elaborationsof responses within the child's own repertoire.

2) Social cognition and flexibilitya) Encouraging empathy, understanding emotions. The assistant and

parents labelled the child's emotions related to ongoing social situationsaiming to increase the child's vocabulary and awareness of emotionswithin self. These real life social scenarios experienced in school andwith peers were presented in a picture cartoon format with thinking andspeaking bubbles. The child was encouraged to identify the emotionwhich related to the event. This involved depersonalizing the experienceand emotion and relating it to another story character. Solutions to thesocial scenario were drawn and the child was asked to identify what




might make it feel better. The aim was to increase insight into otherpeople's emotions and know how change in responses influenced otherpeople's emotions.

b) Enabling flexibility. Flexibility was facilitated by regularly adding onesmall change to the routine. The child was forewarned about anticipatedchanges to enable anticipation and understanding.

c) Understanding social and verbal inferences. Cartoon stories abouttypical social scenarios were used to introduce understanding ofinference. The introduction of metaphors and hidden meaning inlanguage was introduced. The child was supported in making deductionof the likely meaning from the social context. Generalisation wassupported by the assistant interpreting complex language withinsocial and classroom situations on a daily basis.

3) Language pragmatics therapy. This focused on explicit exercises andclassroom support in exchange structure, turn-taking, topic management,conversational skills, building sequences in narrative, referencing indiscourse, cohesion and coherence. The principal aim for both childrenwas to reduce verbosity and to improve coherence and quantity ofinformation offered in conversation.

The therapeutic techniques used in 2 and 3 varied according to the nature ofthe goals stated for an individual but these involved modelling and individualpractice; role-play; practising specific pragmatic skills in conversations;metapragmatic therapy; promoting self-monitoring and coping strategies;rule flouting exercises.

Child A: social communication impairment, normallanguage processing skills

Background and pre-therapy assessmentChild A was aged 9;9 at the start of intervention. He functioned at well aboveaverage on formal tests of sentence construction, verbal comprehension andreceptive vocabulary. His nonverbal performance was at the 75th centile on theRaven's Matrices (see Table 1). He scored at near ceiling on a test of verbalinference (ACE 6-11 Inferential Comprehension) and on the Sentence Recalland Formulating Sentences subtest of the CELF-R. He scored well below thethreshold for autism on the ADI at the time of the study. However, there weresocial developmental factors in his history suggestive of autistic spectrumdisorder: lack of imagination, lack of sharing with adults and peers, tendency




Table 1 Developmental test scores prior to intervention

ACETROG BPVS naming

Age at HavensCase start of Al CCC ADI centile SS %ile SS %ile SS %ileA 9;9 129 13 75 141 99 117 87 11 63B 8;01 109 18 25 77 5 78 7 5 5

CCC=Children's Communication Checklist. Scores less than 132 indicate apragmatic composite likely to be consistent with the presence of pragmaticimpairment; ADI =Autism Diagnostic Inventory. Scores less than 21 indicate anabsence of autism diagnosis on this instrument.

to control play, insisting that peers followed his rules. He showed lack ofverbal reciprocity and intense interests with specific themes including compu-ter games. ALICC assessments pre-therapy (see Figure 1) show his tendencyto dominate the conversation (CD measure high compared to control group)and to be verbose (loquacity measure higher than that of control group; verbalresponsiveness is relatively low compared to control). This appears as aregular feature with children who are relatively verbose. The therapist'squalitative remarks accompanying ALICC defined a tendency to bringtopics back to his own preferred ones. Interactions were disrupted by turn-taking problems. Child A was placed in a mainstream primary school withoccasional advice on interaction skills being provided by the local speech andlanguage therapy services. He did not have a statement of special educationalneeds.

InterventionA's principal needs lay in social aspects of interaction, since he demonstratedexcellent formal language skills and above average comprehension ofinference. There was, however, notable difficulty in adapting to social contextsand some rigidity of leaming evident from his overall profile. A needed tolink up formal linguistic devices which he had mastery over, such as topicchange markers, with the social signals for change of topic indicated inthe interaction. Management therefore aimed to strengthen social interactionand nonverbal aspects of social cognition by using metapragmatic therapytechniques.

Priorities for intervention were therefore:

* to use his above average language skills to reflect upon his own conversa-tional and nonverbal interactional style (Framework section 3);




* To reduce verbosity and conversational dominance and increase verbalreciprocity (Framework sections lb, Id, 3);

* To improve listening and acknowledgment of the interlocutor (Frameworksections Id, 3);

* To develop better understanding of social contextual cues (Frameworksection 2c);

* To develop better understanding of others' intentions and feelings (Frame-work section 2a);

* To develop awareness and understanding of how to adapt communicationstyle according to the social context (Framework section 1d, 3);

* To promote adaptations in interactions amongst educational workers andpeers (Framework sections la, lb, Ic).

These translated into specific aims of

1) Promoting understanding of the conventions of having a reciprocalconversation:* developing insight into conversation rules and identifying conversationalbreakdown in others and self;

* practice in applying the conversational conventions in speaker-listenerturn taking, introducing a topic, maintaining a topic, ending a topic inconversational exchanges.

2) Improving understanding of presupposition using role play:* discriminating between familiar/unfamiliar topics;* identifying the other person's knowledge;* practising introductions and knowing how much information to give.

3) Encouraging equal participation in talk:* allowing specified times only for talk about favourite themes;* establishing a visual prompt to remind A to not allow intrusion of setthemes into conversation at other times.

4) Establishing visual cues to define roles as speaker or listener: picturesof the speaker and listener were presented as cues. The therapists initiatedtalk about a topic, pausing to leave a clue for the interlocutor to speakwhilst having omitted some information. The 'listener' (A) was encouragedto ask questions about the information that was missing. In this way Aworked on* understanding the use of relevant comments and questioning;* establishing strategies for finding/supplying information where sharedknowledge is insufficient;

* establishing the topic of conversations metapragmatically.




5) Developing understanding of social inference and social intentions:* visual cartoons were used to represent typical social interaction and

challenges; solutions to real life challenges were drawn as thought andspeech bubbles;

* identifying his own and others' emotions and colour coding theseaccording to the intensity and classification of the emotions.

6) Generalizing understanding of social situations by the assistant using socialcartoons following challenging social situations.

Outcome of interventionOutcome measures for Child A are shown in Table 2 and in Figure 1. The aimof improving pragmatic skills in discourse was supported in part by modestbut nevertheless visually evident changes in his ALICC profile. Experience ofinterpreting these profiles indicates that a change which is visually evident onthese profiles represents a substantial qualitative change in behaviour. Post-therapy conversation analysis showed predicted changes in domination of theconversation (conversational dominance and loquacity) representing a moreinteractive style of discourse after therapy. He showed no change in responseor pragmatic problems.

Since A functioned at ceiling on language tests, no changes were expectedin these except that there was a further improvement in narrative propositionsscore. Inspection of the narrative transcripts revealed this to be due to adiminished tendency to wander off topic, at least on this task.

Parent and teacher perceptionsParent and teacher views on the outcome of therapy for A were solicited via aplanned telephone interview. Prior to the intervention the parent and teacherreported some rigidity and insistence on own wishes. Their main goals for Awere to have enhanced friendships and flexibility. The school staff felt theyhad been actively involved in the intervention and had gained skills bydiscussing therapy plans and strategies and watching individual sessions ona regular basis. The parents perceived themselves as involved and visited the

Table 2 Pre/post-therapy test scores for Child A

ACE ACE CELF-R CELF-Rinferential narrative sentence form/g

comprehension propositions recall sentences

SS %ile SS %ile SS %ile SS %ilePre-therapy 17 99 13 84 17 99 17 99Post-therapy 17 99 16 98 17 99 17 99




0.8

a ;6 E C Control0. U Child A Pre

xO0.4 ochild A Post

0.2

CD Loq Resp RePr PrPr

Conversational index

Figure 1 Conversation indices for Child A pre/post therapy and control children. Key:CD = Conversational Dominance; Loq = Loquacity; Resp = Responsiveness; RePr =Response problems; PrPr= Pragmatic problems

therapist in school on a weekly basis. They had gained better understanding ofhis needs and the underlying difficulties and coherent strategies at home. Theparents felt they had more conversations at home after therapy and coulddiscuss problems more constructively.

Following the intervention the school reported that A showed betterunderstanding of social situations and other people's feelings. Both his parentsand school staff felt it was easier to have a conversation and he volunteeredinformation more spontaneously about events and his feelings. His motherdescribed how he would tell her more about his day and what happened. Hisaccounts of events were more coherent and easier to follow and he found iteasier to discuss social difficulties and was less impulsive. Both the schoolstaff and parents felt they had changed their approach by talking throughproblems with him more and discussing how to solve them. They found iteasier to access therapy in school as this increased generalization of skills andfound the quantity of therapy appropriate to his needs.

Child B: social communication impairment, moderatelanguage processing impairment

Background and pre-therapy assessmentChild B was aged 8;01 at the start of intervention. Pre-therapy assessmentindicated that he scored below threshold for frank autism on the ADI but hedid present with characteristics of autistic spectrum disorder at an early ageand could be described as having Pervasive Developmental Disorder. His early




developmental history presented with a high level of stereotyped speech,immediate and delayed echolalia and difficulty in shared play and peerinteraction. He preferred adult company to peers and enjoyed solitary play.B had circumscribed interests from a young age including interests in animalsand would talk at length about these. He had little appreciation of conversa-tional skills or social chat. He had limited empathy although was always anaffectionate child with normal integration of eye-gaze, gesture and verbaliza-tion. B presented with some superficially similar characteristics to Child A interms of pragmatics, yet the underlying language profile was quite different. Bpresented as a highly verbose child whose expressive syntactic facility beliedhis limitations in verbal comprehension.

His language profile was similar to that of a child with a severe languageimpairment. At the start of therapy he was functioning in the low centiles ofboth TROG and BPVS and scored at the 25th centile on Ravens. Despite hisfluency, naming skills were also well below average (see Table 1). Errors innaming consisted mainly of semantically related errors and descriptionstypical of specific language disorder:

e.g., whale > sharkflask > tea thing.

There was an indication of some unusual errors however,

armadillo > sort of gladiator (possible visual/semantic relation to armour)pepper > apple (perceptual error).

His naming score was however, commensurate with his limited receptivevocabulary score.

Inferential comprehension and sentence recall at the outset of therapy wereparticularly weak (see Table 3). Although lengthy responses were given to theACE Inferential Comprehension subtest, none were accurate in terms ofunderstanding the overall context and meaning of the story. For instance:

Item 7:Therapist: Why would someone steal something?Child B: It could have been their mum's.

Item 8:Therapist: What will the family do now because of the burglary?Child B: They might have told all the birds to eat from the vegetable patch.

From observation during conversational recording sessions, it was clear that Bfrequently used avoidant strategies to conceal lack of task comprehension.




Conversation analysis revealed his strategies to include commanding the floor,talking over his conversational partner, tangential speech and repetitiveinitiation of set topics relating to animals, gardening and science. B recitedscripts and factual information with little regard to whether his interlocutorwas listening or following his meaning. He had a compulsion to finish histopic, ignoring adult interjections or comments. He had limited insight into hisdifficulties although recognized that he preferred controlling the topic and hadlittle interest in listening to others' topics. In spite of this, B was engaging andsuccessful at eliciting and sustaining adult attention and was generally popularwith adults and peers. He was skilled at using conventional and elaborativegestures and used facial expression to convey emotions, though this was notsubtly done. He had difficulty reading hidden social intention conveyed innonverbal signals and tended to interpret language literally. He also haddifficulty making firm friends, primarily because he was unable to share topicsor themes with peers for any length of time. In class he had great difficultyattending to the topic set in the curriculum and was frequently distracted ontohis own chosen interests. B needed continual one-to-one support to structurehis environment, refocus his attention and direct him to the topic. At the startof the project he had a statement of special educational needs and was on thewaiting list to be reassessed by a speech and language therapist.

InterventionB presented a very different profile of communication from A despite somesuperficial similarities in pragmatic skills. He had significant difficulties withall four dimensions of the development of social communication and, strictlyspeaking, required assistance in developing formal language skills as well aspragmatic skills. Clearly B had significant limitations in comprehensiondevelopment - both at sentence and above-sentence level, which wouldnormally indicate that intervention in social cognition and sentence under-standing would be necessary, but this could not be provided in this study. Thepresence of vocabulary and naming limitations suggested that B had a fairlywidespread developmental language disorder in addition to developmentalsocial problems. The overwhelming nature of his social adaptation and socialinference problems, however, justified his inclusion into a period of socialadaptation therapy.

Intervention priorities were:

* supporting comprehension by adapting language used in the classroom(Framework sections la, lb, lc);




* encouraging equal participation in shared talk by reducing the use oftangential topics (Framework sections 1d, 3);

* develop metapragmatic awareness of listening skills and conversationalskills (Framework section 3);

* develop understanding of social inference and social intentions (Frameworksections 2b, 2c);

* develop the ability to empathize and read other people's emotions (Frame-work section 2a);

* increase flexibility and adaptation to his interlocutor (Framework 2b, 3).

These translated into specific aims of:

* training staff on simplification of language input;* practising turn taking and active listening for topics;* understanding of emotions/intentions and their effects on communication;* introducing, maintaining and ending a topic in conversational exchange;* raising awareness of conversational rules;* constructing sequential narratives in discourse as a means of extending

topics.

B's individual structured intervention sessions focused on listening activelyfor meaning and conversational rules: no interrupting or changing of the topicwas allowed in structured setting in order to demonstrate good practice inobserving the interlocutor's floor. 'Useful' conversation rules were demon-strated as metapragmatic constructs and practised in role play:

being relevant and succinctknowing when to finish to allow a responsepausing for questionsprohibiting switching onto favourite themesshowing interest in the other person's topic

For example, B practised identification of conversational breakdown with thetherapist in sabotage role play using puppets that were scripted to interrupt,switch topic and to talk too much. Finishing a topic was practised using 'guessthe ending of a story' scenario. Visual prompts were used to identify speakerand listener roles and to practise switching roles. B was allowed a set time atthe end of each individual session and each day to talk about his set favouritetopics. At these set times the adult followed his interest and topic ofconversation, at other times the adult redirected B back to the relevant topicunder discussion.




Social stories and comic strip conversation relating to real life experiencesand recent events in school or home were drawn to facilitate understanding ofsocial intentions and problem-solving social or interaction difficulties. Thiswas achieved by the therapist drawing a happy and sad ending followed by Bdeciding on the possible consequences of the social scenarios. Insight andempathy was facilitated by attributing emotions to faces in story books and insocial stories. Real-life conflict situations were presented in a story scenario to

develop insight into his own and others emotions. This was reinforced in theclass and at play time by the assistant labelling emotions and problem-solvingongoing social difficulties.

Narrative skills were targeted in structured interventions by providing a

framework for the story's beginning, middle and end. The therapist modelledcreating a story which was followed by structured activities where the therapistprovided the beginning and middle of a story and the child was asked tocomplete the ending. This was followed by the therapist providing just thebeginning for the child completed the middle and ending. A selection of smallnonrelated objects e.g., lollipop stick, car, block, hair bobble, ball, key, smallglasses were used as prompts for creating the story. The therapist retold thechild's story with pieces of missing or incorrect information; the childcorrected the therapist.

This was followed by training of all adults in his environment at home andschool in the conversational rules and social stories. Key adults, including theteacher and assistant, observed individual sessions and received training onadapting their language input and giving B a strategy for signalling lack ofunderstanding. Adults were trained to refocus the topic to the relevant subjectunder discussion and prompt B when he used tangential speech. Visualsymbols were used to aid generalization of skills.

Outcome of interventionChild B showed a change in profile in a different manner from Child A. HisALICC profile (Figure 2) is similar post-therapy to pre-therapy with, ifanything, an increase in loquacity and dominance, demonstrating what ispotentially an intractable pattern of social communication. Responsiveness fellslightly post-therapy, indicating fewer verbal responses to adult initiations.Response and pragmatic problems remained similar post-therapy. The thera-pist reported that he continued to need prompting to apply appropriate socialand conversation rules to novel social situations.

There were, however, benefits of intervention, albeit not entirely anticipated.B showed substantial gains in scores on formal language tests of recall and




1

0.8

0

0.6

00.41_

0.2

0

Control

M Child B Pre

[Child Post

CD Loq Resp RePr PrPr

Conversational index

Figure 2 Conversation indices for Child B pre/post therapy and control children. Key:CD = Conversational Dominance; Loq = Loquacity; Resp = Responsiveness; RePr =Response problems; PrPr= Pragmatic problems

formulation of sentences and modest, but clinically significant, gains ininferential comprehension and narrative tests (see Table 3). As little changehad been reported in language skills for some time, this effect was thought tobe due to the intervention rather than to spontaneous development, although adegree of practice cannot be ruled out.

Parent and teacher perceptionsPrior to the intervention teachers and parents observed that B had very poorlistening skills in a group, had difficulty participating in reciprocal conversa-tions and tended to talk exclusively about his favourite topics. B's parentsinitially were unaware ofhow to support social communication at home. Theyfelt that they had developed better understanding of his communicationdifficulties and became involved in providing dedicated time for supporting

Table 3 Pre/post-therapy test scores for Child B

ACEinferential

comprehension

SS %ile

ACEnarrative

propositions

SS %ile

CELF-Rsentence

recall

SS %ile

CELF-Rform/g

sentences

SS %ilePre-therapy 3 1 6 9 3 1 8 25Post-therapy 5 5 7 16 8 25 16 98




conversational skills daily. The therapist demonstrated therapy to B's learningassistant and shared information and discussions with all school staff. Theongoing discussions about day-to-day management and how to reinforcecommunication skills in the class were reported to be extremely helpful.The assistant continued the communication programme in individual andsmall group sessions each day.

Following the intervention, the parents reported marked improvementin listening skills, less tangential speech and better conversations. Bothparents and teachers found it much easier to engage B in reciprocal con-versations which were more relevant. They found that he commentedspontaneously about his day, talked less about his set topics, was moredemanding of adult attention and easier to relate to. The teachers reportedgreatly improved listening during carpet discussion time, reduced tangentialspeech, better conversations, thinking about being a good listener in class andfewer interruptions.

Both parents and teachers reported continued generalisation of skillsdeveloped in individual sessions. Both teachers and parents felt the intensityof therapy greatly benefited their child and gave them excellent strategies touse at home. They found school-based therapy much easier for parents andless disruptive to the child.

Discussion

The two cases reported presented similar characteristics in terms of socialcognition, social relations and language pragmatics in the presence of verydifferent language processing profiles. Intervention in the studies describedabove focused on the child's social and language pragmatic skills andproviding support for communication in an educational context. At thisstage of research, remediation of formal language processing was excludedsince we were interested in exploring the responses of children with PLI to thissocial pragmatic intervention. It might be predicted, therefore, that the effectsof the interventions should be seen in changes in social interactions andlanguage pragmatics.

There is some evidence, from the case of A, to suggest that targetingintervention towards social adaptation and pragmatics had an effect ofreducing conversational dominance and verbosity. This is itself a promisingfinding, given the apparent intransigence of social interactional difficulties inthis population and requires further investigation. It should be noted though,that generalization of these skills was not systematically studied and that




problems of conveying information and responding did not show change. Itmay be that this child was able to adapt to a more interactional style ofconversation because of his exceptionally strong linguistic (and metalinguis-tic) skills. If this effect is lasting and contributes towards his social integrationthen this would be a worthy aspiration of intervention indeed, but more proofis needed of lasting, robust effects.

For Child A, pragmatic therapy was successful in redirecting social interac-tions to a more equitable balance of dominance. Given that the pragmaticbehaviours under inspection appear to be so firmly fixed in his style ofinteraction, this is an important finding. Moreover, from a parent's and teacher'sperspective, changes emerged which were positive and meaningful for the well-being of A since better social integration was reported. The parent-teacherrapport and appreciation of training for support staffwas an integral part of thisprocess. This indicates clearly that impairment-based therapies and indirectapproaches to supporting communication in the natural environment can besuccessfully combined in one approach to management of complex needs.

Child B showed characteristics of developmental language disorder inaddition to social interactional and social cognition problems. The socialadaptation and pragmatics intervention was adapted to his individual needs butfollowed similar principles to that of Child A. In B's case there was far morepotential to show change in standardized language scores. B showed signifi-cant changes in his ability to organize and formulate individual sentences - afeature which must be representative of generalized skill development, since itwas not directly targeted in therapy. He showed modest but real improvementson tests of inference and prepositional content of narrative. But he showedlittle or no change in conversational profile, demonstrating resilience to thetherapy which had targeted his loquacity and tendency to dominate. There areseveral possible explanations for these results: a) that B is showing sponta-neous progress in language processing. This is unlikely since an inspection ofcase notes suggests little change over the last year; b) that there is somegeneral effect of therapy - it is possible that participation in intervention whichfocuses on contingent interactions has some general language improvementeffect. However, changes in formal language pragmatics as well as changes inlanguage processing should therefore occur and this was not the case; c) thatthe effects of adapting input to promote listening and social engagement havehad the effect of drawing the child into better deductions about the languagelearning process. This may account for the breadth of change andfor unexpected progress in non-trained aspects of language; d) that therapyhas had the effect of training listening and comprehension almost inci-dentally (as outlined in c) but that language pragmatics will not show




change until the formal language system is stable enough to support meta-pragmatic reflection.From an experimental viewpoint it would have been interesting to treat B's

vocabulary and sentence comprehension and monitor the effects of languageprocessing therapies on pragmatic skills and social interaction. In suchcomplex cases the contribution of strategic avoidance of engagement incommunication (due to experience of failure) complicates the profile andshould not be underestimated. Indeed, in both cases there were clear indica-tions that self-esteem and behavioural issues were contributory to increasinglydifficulties with peer relations. These too need to be the focus of overallmanagement and be part of the evaluation of communication interventions.All we can conclude satisfactorily is that children do show positive changesas a result of this therapy - it is not always clear what triggers these changesin complex cases, though the results of Child A show that social adaptationand pragmatics therapy can have a direct effect on measurable pragmaticskills.The two cases illustrate the effects of a narrow window of direct specialist

intervention supported by dissemination to parents and co-workers. Theintensive nature of the intervention was dictated, in this instance, byavailability of research funding. Nevertheless it enabled the therapist toembrace all aspects of both within-child and environmental factors whichimpacted on the presenting picture. If short term intensive intervention canproduce changes in communication skills over and above long term advice andmonitoring within a 'consultancy' model, is this one which should beadopted? What will be the resources necessary to support this?We predict that limitations of intervention will become evident in the

process of further research. Social developmental problems are persistent. Itmay be that direct therapies, focusing on impairment only, may be of limitedeffectiveness for children with intractable problems of social cognition or thatindirect approaches have limitations in accessing change in language proces-sing skills. One of the prime functions of case studies is to raise good researchquestions. There are few confident guidelines regarding the optimal interven-tions for children with PLI. It is a matter of concem that there is no hardevidence to support the present service commitments. Besides the obviousquestions of the 'does it work?' variety, detailed examination of the results canprovide a direction for further projects, pushing the boundaries of interventionresearch forward. There is a need for systematic approaches to carefully-controlled therapy for clearly identified groups of children with PLI in order tofind answers and to establish an intervention policy which will promoteeffective practice.




AcknowledgementsWe would like to acknowledge the participation of A and B, their parents,teachers and support workers; also the speech and language therapists whoreferred children to the study and provided supportive information. This researchwas supported by an ESRC Realising Our Potential Award to the first author.

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Appendix

Recommended published materials for pragmatic language interventionand key supportive textsAnderson-Wood, S. and Smith, B. R. 1997: Working with pragmatics.

Bicester: Winslow.Black Sheep Press Speech and Language Therapy Resources. Activities for

pragmatics and semantics. http://www.blacksheep-epress.com




Bliss, L. S. 1993: Pragmatic language intervention: interactive activities.USA: Thinking Publications.

Brinton, B. 1989: Conversational management with language-impairedchildren. Rockville: Aspen.

Duchan, J. 1995: Supporting language learning in everyday life. San Diego:Singular.

Firth, C. and Venkatesh, K. 1999: Semantic-pragmatic language disorder.Winslow: Bicester.

Gray, C. A., White, A. L. and McAndrew, S. 2002: My social stories book.London: Jessica Kingsley.

Johnston, E. B., Weinrich, B. D. and Glaser, A. J. 1991: A sourcebook ofpragmatic activities (revised). San Antonio: Communication SkillsBuilders.

Paul, R. 1992: Pragmatic activities for language intervention (PALI).San Antonio: Communication Skill Builders.

Naremore, R. C., Densmore, A. E. and Harman, D. R. 1995: Languageintervention with school age children: conversation, narrative and text.San Diego: Singular.

Naremore, R. C., Densmore, A. E. and Harman, D. R. 2001: Assessment andtreatment ofschool-age language disorders. San Diego: Singular.

Rinaldi, W 2001: Social use of language programme (SULP) - Revised.Windsor: NFER-Nelson.



pragmatic language impairment: case studies of social and pragmatic language therapy

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