pragmatic use of language by children who develop schizophrenia in adult life

Schizophrenia Research xxx (2013) xxx–xxx

SCHRES-05351; No of Pages 6

Contents lists available at SciVerse ScienceDirect

Schizophrenia Research

j ourna l homepage: www.e lsev ie r .com/ locate /schres

Pragmatic use of language by children who develop schizophrenia in adult life

D. John Done ⁎, Eeva Leinonen 1

Dept. Psychology, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, UK

⁎ Corresponding author. Tel.: +44 1707286292.E-mail addresses: [email protected] (D.J. Done),

(E. Leinonen).1 Present address: University of Wollongong, Australi

0920-9964/$ – see front matter © 2013 Elsevier B.V. Allhttp://dx.doi.org/10.1016/j.schres.2013.03.005

Please cite this article as: Done, D.J., Leinonen(2013), http://dx.doi.org/10.1016/j.schres.20

a b s t r a c t
a r t i c l e i n f o
Article history:Received 6 December 2012Received in revised form 8 February 2013Accepted 5 March 2013Available online xxxx

Keywords:SchizophreniaNarrative coherence and cohesionPre-morbid languagePre-morbid executive ability

At eleven years of age all children in a UK national birth cohort wrote short stories about the life theyexpected to be leading at age 25.Using a data linkage exercise, we identified those who later developed schizophrenia, affective psychosis, orother non-psychotic psychiatric disorders in later life based on the PSE CATEGO diagnostic system. Themajority of these had completed the written essays. Controls from the reference population were selected,matched for gender, IQ and social and economic status.The essays were scored using well established methods for assessing pragmatic use of language, namelynarrative coherence and linguistic cohesion.We hypothesised that children pre-morbid for schizophrenia (Pre-Scz) would obtain low scores on all thesemeasures. However this general hypothesis was largely disproved by the data, although some unpredictedgender effects were found.It is concluded that thought is organised in an unexceptional way in adolescents before they develop schizo-phrenia, once the data are corrected for any lowering of general cognitive ability in the Pre-Scz cases.

© 2013 Elsevier B.V. All rights reserved.

1. Introduction

Pragmatics within the discipline of linguistics examines how so-cial context combines with the verbal form of an utterance to createmeaning for the listener. Idioms such as “I've had it”, “I'm done withthis” require appreciation of the social context to be properly under-stood, which is also true of proverbs, metaphors and irony. Pragmat-ics is just as relevant to written language too. We understand thenotice in a shop window “Baby Sale — lots of bargains” to be abouta specific clothes sale, not a sale of babies.

A considerable body of work has focused on the pragmatic ability ofpeople with schizophrenia in the comprehension of metaphor andirony (e.g. Corcoran and Frith, 1996; Langdon et al., 2002). Much of thisresearch has also become seminal work in the debate about Theory ofMind (ToM) disorders in schizophrenia too (e.g. Frith, 2004; Brune andBodenstein, 2005). Indeed Grice (1969), who introduced pragmatics tolinguistics, regarded pragmatics to be the process of inferring thementalstates of the listener. Sperber andWilson (2002) also note the theoreticaloverlap between pragmatics in linguistics and ToM in psychology.

With regard to disturbance of speech production in schizophrenia(nb formal thought disorder), a number of researchers have sug-gested that this is a disorder of pragmatics rather than semantics orsyntax (e.g. Frith and Allen, 1988; Sass, 2003).

[email protected]

a.

rights reserved.

, E., Pragmatic use of languag13.03.005

Two of the most widely used methods for measuring pragmaticuse are lexical cohesion and narrative coherence. These are distinctin terms of their respective measurement criteria (Carrell, 1982).

Cohesion refers to the use of specific words, often referred to as‘cohesive ties’, or grammatical links whose purpose is to tie sentences,phrases or clauses together in order to convey an intended meaning.Pronouns e.g. he, it, that, are especially important cohesive ties sincethey indicate to the reader that the subject is the same as that de-scribed in a previous sentence.

Cohesion analysis, developed by Halliday and Hasan (1976) hasbeen extensively used in the study of language disturbance in schizo-phrenia. Reduced use of cohesive ties distinguishes thought and non-thought disordered speech in adults (Rochester and Martin, 1979;Harvey, 1983), and childhood schizophrenia (Caplan, 1994). In additionsome studies of pre-psychotic high risk children have found reduceduse of cohesion (Harvey et al., 1982; Gooding et al., 2010) althoughothers reported negative findings (Griffith et al., 1980; Parnas andSchulsinger, 1986).

Coherence refers to the organisation of ideas in a narrative. Localcoherence occurs when there is elaboration on a theme, typically inan adjacent clause. Global coherence refers to the organization ofthemes across the whole narrative to generate a complete story. Inboth local and global coherence the writer (or speaker) is trying to in-fluence the reader's understanding. Good coherence requires the in-troduction of appropriate themes, together with local elaboration(Bamberg and Damrad-Frye, 1991) and a systematic and logical struc-ture of these themes to form a coherent narrative (Tiernay andMosenthal, 1983; Liles, 1993).

e by children who develop schizophrenia in adult life, Schizophr. Res.

http://dx.doi.org/10.1016/j.schres.2013.03.005

mailto:[email protected]

mailto:[email protected]

Unlabelled image


Unlabelled image

http://www.sciencedirect.com/science/journal/09209964


Table 1National Child Development Study (NCDS): Pre-morbid cases (PSE CATEGO classifica-tion) and controls.

Schizophrenia(S+)

AffectivepsychosisM+/M?,D+/D?

Non-psychoticpsychiatricdisorderN+/N?

Healthycontrol

No. documented byteacher at age 11

30 31 70 13,953

No. with essays availablefor analysis(% documented byteacher)

22(73%)

24(77%)

56(80%)

64a

(80%)

IQ Mean (SD) 91.9(16.9)

94.5(13.8)

93.5(13.5)

95.3(14.5)

Social and Economic Statusb

Median (Range)4 (1–6) 4 (1–6) 4 (1–6) 4 (1–6)

a This is the sub-sample of control cases matched according to the criteria men-tioned in the text.

b Based on the occupation of child's father using General Registrar's Office of GreatBritain, 1960. Classification of social class: 1 = professional, 2 = intermediate groups,3 = Skilled non-manual, 4 = skilled manual, 5 = Semi-skilled non-manual/manual,6 = Unskilled manual.

2 D.J. Done, E. Leinonen / Schizophrenia Research xxx (2013) xxx–xxx

Of the few studies of narrative coherence in psychosis, reducednarrative coherence has been reported in adult patients, who werenot necessarily thought disordered (Tavano et al., 2008; Raffard etal., 2010; Saavedra, 2010). In the Danish birth cohort, pre-morbidchildren aged 10–13, who later developed schizophrenia, were im-paired on spoken storytelling, although the only measure recordedwas ‘perspective taking’ or the ability to tell the story from anotherperson's perspective (Schiffman et al., 2004). We could find no stud-ies which have examined pragmatic language in pre-morbid children,or adolescents, which analysed the coherence of spoken, or writtennarratives.

The development of narrative ability increases steadily from age8 years through age 16 years (Roth and Speckman, 1986; Purcelland Liles, 1992) This may well be related to the substantial anatomi-cal and neuronal changes to the various pre-frontal structures duringthis period (Blakemore and Choudhury, 2006). This is supported byneuropsychological findings in adults with brain injury extendinginto this region who show impairment in narrative production(Mar, 2004), although others have reported a greater role for the hip-pocampus (Kurcek and Duff, 2012).

In the study reported here we examined the use of narrative coher-ence, and cohesion, in written narratives produced by eleven year oldadolescents who later either developed schizophrenia (Pre-Scz) or af-fective psychosis (Pre-AP) or other non-psychotic psychiatric disorders(Pre-NPPD) in adult life. We propose the following main hypothesis:

1. Pre-Scz adolescents will show poorer use of pragmatics duringcommunication due to reduced use of cohesion and coherencewhen compared to their peers who did not develop any psychiatricdisorder in early adulthood (limited pragmatics hypothesis).

2. The frequency of bizarre or abnormal pragmatics will be foundmore frequently in the Pre-Scz adolescents than in their peerswho did not develop any psychiatric disorder in early adulthood(abnormal pragmatics hypothesis)

3. Neither the limited, nor abnormal, pragmatics hypotheses willapply to the Pre-AP and Pre-NPPD adolescents.

2. Materials and method

2.1. Patient and control samples

Participants are members of the National Child DevelopmentStudy (NCDS), an ongoing follow-up of a birth cohort, which included98% (N = 17,419) of all registered births in the UK in the week of3rd–9th of March 1958 (Centre for Longitudinal Studies, 2013). Vari-ous questionnaires and tests were completed at 8 follow-ups. In thisstudy we utilise data collected at age 11 years (N = 15,145).

2.2. Psychiatric status after age 16

After obtaining ethical approval, a systematic search of computerisedrecords in the UK's National Health Service (NHS) was conducted toidentify individuals admitted to psychiatric hospital between 1974 and86 (aged 16–27), with a date of birth likely to make them NCDS cohortmembers (see Done et al., 1991 for more detail). We then linked theNHS and NCDS identifiers. From the case note histories psychiatric diag-noses were made by a psychiatrist based on the Present State examina-tion (PSE) CATEGO system (Wing et al., 1974). The CATEGO diagnosis ofschizophrenia (S+) is defined by the presence of one or more ofSchneider's first-rank symptoms. M+/M? corresponds to mania andmixed affective psychosis; D+/D? corresponds to depressive psychosis;N+/N? corresponds with non-psychotic psychiatric disorders (NPPD).

Although such a data linkage approach can miss out less severecases of mental disorder, it is unlikely to miss cases of schizophrenia,as only a small proportion of such patients did not have contact withhospitals in this period before the rise of Early Intervention in

Please cite this article as: Done, D.J., Leinonen, E., Pragmatic use of languag(2013), http://dx.doi.org/10.1016/j.schres.2013.03.005

Psychosis and other community teams in the UK (McCreadie, 1982;Eaton, 1985).

49 S+/S? cases were obtained giving an estimated life time risk of0.4 (men) and 0.32 (women) (see Done et al., 1991 for the calcula-tion). The population estimate for morbid risk of S+ is 0.26–0.54%(Jablensky et al., 1992) which compares favourably. 35/49 casescould be linked to NCDS records.

A sub sample of matched control subjects (n = 70) was takenfrom the original cohort, blind to that control's performance on theessay.

2.3. Materials

At the age of eleven the NCDS participants were asked to write anessay with the following instructions: ‘Imagine that you are NOW25 years old. Write about the life you are leading, your interests,your home life and your work at the age of 25 (You have 30 minutesto do this)’. The students were supervised throughout by their classteacher. The essay thus provides a substantial piece of narrative foradolescents of this age.

Choice of narrative is important if it is to provide a sensitive indexof developmental level. These instructions requested a free genera-tion of narrative, as opposed to other narrative elicitation methodssuch as reciting a story. Vocabulary age and verbal IQ also influencenarrative production (Griffith et al., 1985) and hence we matchedcases and controls on a measure of verbal IQ used in the NCDS (seeTable 1). At age 11 all students completed The General Ability Test,which comprised of verbal and non-verbal multiple choice tests sim-ilar to contemporary IQ tests e.g. shown the example: “Chase, Pursue,Capture, Catch” find the missing word to complete “Hunt, Seek, Find,?????”. Participants had to select the missing word (Discover) from achoice of 5. Other confounding variables used in the matching processincluded i) gender, since girls' essays were longer than boys, ii) geo-graphical region in the UK, and iii) social class (given the reportedfindings of Richardson et al., 1976).

2.4. Methods of data analysis

2.4.1. CoherenceIn order to evaluate the hypotheses we first had to establish a sys-

tem for measuring coherence. The scoring system, based on theguidelines provided by Liles (1993) and Bamberg and Damrad-Frye(1991) is presented in Appendix A. The system measures whetherthe number of requested themes (n = 4) are mentioned and in an



Table 2Narrative Coherence Scores —Mean (S.E.) or frequency (% of group) for categoricaldata.

Group

Dependent variable ControlN = 63

Pre-SczN = 22

Pre-APN = 24

Pre-NPPDN = 56

Freq. appropriate themes 2.4(0.1)

1.96⁎

(0.2)2.0ns

(0.2)2.2ns

(0.1)Freq. abnormal themes 6

(9.5%)2ns

(8%)3ns

(12.5%)7ns

(13%)Ordering (appropriate score) 22.0ns

(1.0)25.4ns

(2.6)24.7ns

(1.3)23.4ns

(1.2)Ordering (inappropriate score) 4.2ns

(0.4)4.1ns

(0.7)3.4ns

(0.5)4.3ns

(0.4)All evaluative devices 10.5

(0.6)10.7ns

(1.4)9.8ns

(1.3)9.4ns

(0.7)

For case–control comparisons.ns p > 0.05 for case–control comparison.⁎ p b .05.

3D.J. Done, E. Leinonen / Schizophrenia Research xxx (2013) xxx–xxx

appropriate order (global coherence) and it also measures local co-herence by quantifying the use of sub-themes and ‘evaluations’which the writer uses to develop a theme for maximal effect in thereader. Evaluation is sometimes referred to as ‘metanarrative’ sincethe writer recognises the need to supplement their description ofthe theme to convey the full intended meaning (Bamberg andDamrad-Frye, 1991). Limited use of coherence is deemed to occurwhen low coherence scores are obtained although the themes, theirordering or their elaboration is appropriate. Abnormal coherence re-sults when inappropriate themes / ordering / elaboration occurs.

Inter-rater reliability for coherence measures can be poor unlessthe scorers are highly trained (Liles, 1993). We recruited a lecturerin linguistics (Principle Rater) who had been trained in scoring tran-scripts for coherence and cohesion. Initially the Principle Rater andone of the authors (EL) worked through some sample essays toagree on scoring procedure. The Principle Rater subsequently scored20% of the essays blind as to whether they were cases or controls. Arandom sample of 10 of these was then scored by EL blind to thescores of the Principle Rater. Inter-rater reliabilities at this stagewere high (see Section 3.1) and so the Principle Rater continued asagreed with the remainder of the essays.

2.4.2. DecontextualizingGiven the topic, the narrator is required to imagine the future. We

refer to this as ‘decontextualizing’ since the narrator is required towrite a narrative from a perspective of being a 25 year old rather thanfrom the currentmoment in time. This requirementhasmanypragmaticsimilarities to the perspective taking reported by Schiffman et al. (2004)to be deficient in adolescents pre-morbid for schizophrenia. The scoringcriteria are presented in Appendix B.

2.4.3. CohesionThe framework for cohesion analysis was based on that of Halliday

and Hasan (1976) using their 10 measures of cohesive ties (seeAppendix C). Wikipedia – cohesion (linguistics) – also provides avery useful introduction to the ways in which cohesion can be mea-sured. This scoring framework does not permit separate scores for‘limited’ as opposed to ‘abnormal’ cohesion. For reliability a similarprocess was followed to that described in Section 2.4.1 for the coher-ence measures using the same sample of 10 essays.

3. Results

3.1. Coherence

The average intraclass correlation (ICC) between the 2 raters, tak-ing all measures of coherence, was +0.91 (95% CI = .84–.98) signify-ing high inter-rater reliability.

Since the hypotheses require separate comparisons of each pre-morbid group (Pre-Scz, Pre-AP, Pre-NPPD) vs controls, three separateANOVAs were calculated for each measure.

Gender was included as the second factor in the ANOVA, since theaverage essay length in the healthy control group was 228.8 wordsfor girls and 180.7 words for boys which was statistically significant.(t (60) = −3.1, p b .01).

3.1.1. Frequency of themes

3.1.1.1. Appropriate themes. In the healthy control population, girls pro-duced a greater number of appropriate themes than boys (t (60) =−3.1, p b .01). This might be expected given the longer essays of thegirls.

For the main effect of Group, Pre-Scz adolescents produced signif-icantly fewer appropriate themes than controls (p = .03). A similartrend was noted in both Pre-AP and Pre-NPPD adolescents compared


to controls (see Table 2) although this failed to reach statistical signif-icance (p = .10 in both cases).

The Group by Gender interaction was significant in the Pre-Scz vsControl ANOVA, (F 1, 82 = 6.1, p b .02). Pre-Scz girls produced signifi-cantly fewer themes than the control girls whereas Pre-Scz boys pro-duced a similar number of themes as the control boys. A similarinteraction was found for the Pre–NPPD cases vs Controls ANOVA(F1,111 = 5.8, p b .05) in which the pre-NPPD girls produced fewerthemes than control girls (t (56) = 2.75, p b .01) whereas Pre-NPPDboys produced a similar number of themes (t(55) = −0.75, p = .46)to control boys. For the Pre-AP vs Controls ANOVA the Group by Genderinteraction was not significant.

3.1.1.2. Inappropriate themes. The frequency of occurrence of inappro-priate themes was very low. Therefore participants were coded on thebasis of whether they produced ≥1 inappropriate theme or none.Using this categorical measure no group differences were found.The data are presented in Table 2. It should be noted that only onemale (8%) and one female (8%) from the Pre-Scz group produced aninappropriate theme.

3.1.2. Ordering of themesData are presented in Table 2.

3.1.2.1. Appropriate ordering of themes and sub-themes. Scoring criteriaare provided in Appendix A. All of the pre-morbid groups producedslightly higher average scores than their matched controls (seeTable 2), signifying better scores on this measure, although this differ-ence was not statistically significant in any of the three analyses. Nointeractions with gender were found either.

3.1.2.2. Inappropriate ordering of themes and sub-themes. Scoringcriteria are provided in Appendix A. A higher score indicates greater ab-normality. All groups of cases produced similar scores to those of thecontrols (see Table 2). No group comparison remotely approached sta-tistical significance (min p = 0.3). The Group by Gender interaction inall three analyses was not significant.

3.1.3. Evaluation of themes (metanarrative)The summed score was corrected for total number of clauses in

each essay. Results are presented in Table 2. For all of the 3 ANOVAsthe main effect of group failed to reach statistical significance (minp = 0.3). This result indicates a comparable use of evaluation(metanarrative) in each of the pre-morbid groups to that used bythe healthy control group.



Table 3Cohesion analysis — Means (S.E.).

Controln = 67

Pre-Sczn = 22

Pre-APn = 25

Pre-NPPDn = 56

No. clauses 25.2(1.8) 29.3 (3.3) 28.1 (4.2) 26.5 (2.3)Lexical cohesion 32.0 (1.7) 28.8 (2.1) 28.6 (2.0) 29.3 (1.4)Explicit reference 5.9 (0.6) 5.4 (0.9) 5.8 (0.9) 7.6 (0.8)1

Situational reference 17.2 (1.0) 18.2 (1.1) 15.5 (1.2) 16.3 (0.8)Implicit reference 1.4 (0.2) 1.8 (0.5) 1.3 (0.3) 1.5 (0.2)Unclear reference 1.0 (0.3) 1.3 (0.6) 2.3 (1.0) 1.2 (0.5)Ambiguous reference 0.0 (0.0) 0.1 (0.1) 0.0 (0.0) 0.0 (0.0)Generic reference 1.8 (0.3) 1.7 (0.4) 2.8 (0.5) 1.8 (0.3)Substitution 0.3 (0.1) 0.4 (0.2) 0.2 (0.1) 0.2 (0.1)Ellipsis 0.4 (0.1) 0.35 (0.1) 0.4 (0.1) 0.3 (0.11)Conjunction 10.6 (1.1) 9.4 (0.9) 10.5 (1.1) 10.2 (0.7)

All other comparisons of cases and controls were not statistically significant (p > .05).1 p b .1 (2-tailed).


The Group by Gender interaction was highly significant for thePre-Scz cases vs controls ANOVA (F 1, 80 = 8.55, p b .01). Pre-Sczmales used fewer evaluations than the control males (t (40) = 2.2,p b .05) whereas Pre-Scz females used more evaluation than controlfemales, (t (40) = −1.9, p = .06). A large gender difference in thePre-Scz group was noted, with males (Mean (SD) = 7.1(0.9)) usingfewer evaluations (p b .01) than females (Mean (SD) = 13.9(2.06)).No such gender difference was found in the healthy controls.

This Group by Gender interaction was not significant in either thePre-AP vs controls ANOVA (p = .6) or the Pre-NPPD vs controlsANOVA (p = .8).

3.1.4. DecontextualizingNo significant differences between any of the 3 pre-morbid groups

and the control children were found. Subgroup analysis by gender forthe Pre-Scz group also did not reveal any group differences.

3.2. Cohesion

For cohesion it is important to take account of essay length. Thusall measures were adjusted for the total number of clauses in eachessay. Since most studies have summed across these 10 measures ofcohesion, we also used a summed score.

Pre-Scz cases did not differ significantly from controls (p = .5),nor did Pre-AP cases (p = 0.6) or Pre-NPPD cases (p = 0.4).

For the Group by Gender interaction a significant result occurred forthe analysis of the Pre-Scz cases vs Controls (F1, 83 = 4.3, p b .05). Thiswas predominantly due to a reduced total cohesion score in the Pre-Sczgirls, compared to their controls, (t (40) = 2.0, p b .05).

Table 3 also presents the mean scores for the 10 separate measurestogether with simple t-tests comparing each group of cases with thecontrols. On none of the 10 t-tests was there any statistically significantdifference between Pre-Scz cases and controls.

For the comparisons of Pre-AP and Pre-NPPD cases with controlsthe Group by Gender interaction was not statistically significant.

4. Discussion

In this study we reported results from an analysis of the pragmaticlanguage use in the written works of 11 year old adolescents whowere either pre-morbid for adult schizophrenia (Pre-Scz), or affectivepsychosis (Pre-AP), or non-psychotic psychiatric disorder (Pre-NPPD).Two measures of pragmatic use of language were used: coherenceand cohesion. For coherence we scored on the basis of i) limited coher-ence i.e. quantitatively inferior, ii) abnormal use of pragmatics i.e. odd,bizarre or qualitatively distinct. Pre-Scz adolescents showed limiteduse of coherence on onemeasure only, namely the use of fewer themes.Their ordering of themes and sub-themes, and their use of evaluationsto add emphasis where required were comparable to the controls. We


found no signs of any abnormal use of coherence in the Pre-Scz partic-ipants. A similar pattern of results for coherence was found in the ado-lescents pre-morbid for affective psychosis (Pre-AP) or non-psychoticpsychiatric disorder (Pre-NPPD) too. Both groups produced fewerthemes, although this finding was not statistically significant. On allother measures of coherence their scores were similar to those of thecontrols.

For the cohesion analysis there were no statistically significant dif-ferences in any of the analyses which compared each group ofpre-morbid cases with controls.

Therefore taking into consideration both coherence and cohesion,the Pre-Scz cases differed little from the healthy controls, and thiswas true for the Pre-AP and Pre-NPPD too.

Poor narrative coherence has been reported in childhood onsetpsychosis using a similar measure to the coherence measure used inthe current study (Caplan, 1994). However we could find no studiesof pre-morbid narrative coherence hence there is no comparable liter-ature against which to compare our findings of narrative coherence. Ifpoor coherence or poor use of cohesive ties did occur in Pre-Scz chil-dren then a high frequency of ‘expressive’ language impairmentswould be expected. Cannon et al. (2002) reported normal expressivelanguage in their Pre-Scz sample; Bearden et al. (2000) found a greaterrisk of unintelligible language in 7 year old Pre-Scz children, but thisoccurred with a frequency of only 14% andWatt (1978) found that al-though teachers reported poor language skills in Pre-Scz adolescents,they had not controlled for a potentially lower IQ. So poor coherenceand cohesion seem unlikely in Pre-Scz children once any deficit in IQis taken into consideration.

There is plentiful research on cohesion analysis though. Our resultsare in line with the findings of normal cohesion reported in high riskchildren by Griffith et al. (1980), and Parnas and Schulsinger (1986).However it should be emphasised that the Pre-Scz group in the cur-rent study had low IQ scores (Schulz et al., 2012), and since IQ corre-lates with some measures of pragmatic ability (Barragan et al., 2011)they may well have obtained below the average for their age on cohe-sion and coherence if we had not controlled for IQ.

We did find a number of significant gender differences in thePre-Scz group, which were not predicted a priori since boys andgirls perform similarly on pragmatic language tasks (Barragan et al.,2011). This suggests that there may be notable qualitative differencesin language production of Pre-Scz girls and boys which has not beenreported previously in pre-morbid children (e.g. Bearden et al.,2000; Cannon et al., 2002) although this might have resulted fromlimited statistical power given the categorical measures used andthe small sample size. However our findings are not surprisinggiven some reports of gender differences in Pre-Scz adolescents onmeasures of interpersonal behaviour (Watt, 1978; Done et al., 1994)and the importance of pragmatics in forming and maintaining peerrelationships.

The measure of decontextualizing assessed the participants' abilityto take an imaginary perspective (nb life at the age of 25). This is similarto the perspective taking in the study by Schiffman et al. (2004).Where-as Schiffman et al. (2004) did report impaired perspective taking intheir Pre-Scz adolescents we found this to be normal for age.

Narrative production appears to make heavy demands on executiveskills in order to generate good coherence and metanarrative. Damageto pre-frontal cortex does put limits on narrative as well as executiveability (Janowsky et al., 1989; Godbout and Doyon, 1995; Mar, 2004).We therefore conclude that the executive skills of Pre-Scz adolescentswere within the normal range on this writing task, having adjustedfor the lower IQ. However this finding may mask important genderdifferences.

In conclusion we found that 11 year adolescents, pre-morbid forschizophrenia had neither limited pragmatic ability nor did they gen-erate any bizarre narratives. Thus if pragmatic language disorder doesoccur in adult onset schizophrenia then either this emerges in the



5D.J. Done, E. Leinonen / Schizophrenia Research xxx (2013) xxx–xxx

prodromal phase, or post-onset, or is state dependent only occurringin periods of thought disorder.

Role of funding sourceJohn Done and Eeva Leinonen were both employed by the University of Hertford-

shire. The MRC (UK) provided grant support for Amanda Sacker to collect the essays.

ContributorsJohn Done conducted the data linkage part of the study including accessing the

case records. He also conducted the statistical analysis and contributed his share towriting the paper.

Eeva Leinonen developed the scoring measures for coherence, meta-narrative andcohesion and recruited and trained a skilled linguist to complete the scoring of eachscript. She also contributed her share to writing the paper.

Conflict of interestNone.

AcknowledgementsThe authors would like to thank the Centre for Longitudinal Studies, and especially

Peter Shepherd, and Kevin Dodwell. Also Amanda Sacker for obtaining the originalessays from the archives. The MRC (UK) for grant support for Amanda. Also thanksto Tim Crow for his enthusiasm and creative ideas, and Phil Harvey for useful advice.

Appendix A. Narrative coherence — definitions and operationalcriteria for scoring

The title of the essay asked the children to write about 4 topics orthemes, namely “the life you are leading, your interests, your homelife and your work”.

1. Frequency of Themesi) Appropriate themes

Score 1 for each appropriate theme. Use the sum score.ii) Inappropriate themes

Score 1 for each inappropriate theme. Use the sum score.2. Ordering of Themes

i) Ordering of appropriate themes and sub-themesScore 1 for each newly introduced and appropriate theme, orappropriate and contingent subtheme. Use a sum score.

ii) Frequency of inappropriate themes and sub-themes.Score 1 for each subtheme, or theme that was inappropriate, orwhen a sub-theme was not contingent with its main themes(i.e. did not follow on appropriately). Use a sum score.

3. Evaluation of themes (metanarrative).Score 1 for each occurrence of the following:a. Hedges (see Wikipedia — hedges(linguistic)

Informing the reader of your expectations, or uncertainty abouta precise value or specification.e.g. “I have a car. It's kinda red with a blue stripe down the mid-dle from back to front.”

b. The use of a negative for evaluatione.g. “I try not to spend too much money.”

c. Causal evaluationse.g. “Today is Wednesday and it is very busy in the morningbecause as you know early closing day is Wednesday.”

c. Intensifierse.g. “I was very astonished for a minute.”

d. Frames of mind (e.g. knowing, being interested in something,being frightened)These refer to mental states of the writer or others. e.g. “Shecould not believe the news.”

Appendix B. Categories of decontextualizing

Category 1. Future expressed appropriately using ‘past and presenttense’e.g. “I got married when I was 17, and had children at 20.I work as an airline pilot….”


Category 2. Future only expressed in the present tense e.g. “I ammarried with 2 children…”

Category 3. Minimal decontextualizing — the future is expressedwith future tense e.g. “I will be married with 2children…” (Future expressed in the future tense)

Category 4. No decontextualizing due to describing the present. e.g. I amat school and I live in Manchester

Appendix C. Cohesion measures — definitions and operationalcriteria for scoring

Each occurrence of the following obtains a score of 1

1. Lexical cohesionThis refers to the repetition, in successive clauses, of the sameword, a synonym, a word from the same root, or a general termthat is related to the earlier clause.e.g. “I live in a big house. Our house is the nicest one in our street.”

2. Reference (6 measures)Referential cohesion is the process of relating information in oneclause/sentence to an earlier clause/sentence, typically with pro-nouns. 6 different measures were used.

Explicit reference: “Simon's job is a football player. He plays for 1stShipman.”Situational reference: “Look at that”Implicit reference: “I would be a mechanic. Working at Dunn'sgarage…”

Unclear reference: “I like the film.” (No previous or subsequentmention of film).Ambiguous reference: “My Dad and Granddad work all hours. He isfed up with it.”Generic reference: “The people didn't mind.”

3. SubstitutionThe meaning of a word such as ‘one’, or ‘ones’ needs to be recov-ered from a previous or a following sentence/clause. E.g. “I won'thave a husband. I wouldn't want one.”

4. EllipsisA sentence/clause is grammatically incomplete and hence meaningis left unsaid and needs to be recovered from a previous sentence/clause.e.g. “I aren't married but (I am) engaged to a girl in third year at myold college.”

5. Conjunction:“And, but, when, or” are words whose sole purpose is to joinphrases/sentences together

References

Bamberg, M., Damrad-Frye, R., 1991. On the ability to provide evaluative comments:further explorations of children's narrative competencies. J. Child Lang. 18,689–710.

Barragan, M., Laurens, K.R., Navarro, J.B., Obiols, J.E., 2011. ‘Theory of Mind’, psychoticlike experiences and psychometric schizotypy in adolescents from the generalpopulation. Psychiatry Res. 186, 225–231.

Bearden, C.E., Rosso, I.M., Hollister, M., Sanchez, L.E., Hadley, T., Cannon, T.D., 2000. Aprospective cohort study of childhood behavioural deviance and language abnor-malities as predictors of adult schizophrenia. Schizophr. Bull. 26 (2), 395–410.

Blakemore, S.-J., Choudhury, S., 2006. Development of the adolescent brain: implicationsfor executive function and social cognition. J. Child Psychol. Psychiatry 47 (3/4),296–312.

Brune, M., Bodenstein, L., 2005. Proverb comprehension reconsidered — ‘theory ofmind’ and the pragmatic use of language in schizophrenia. Schizophr. Res. 75,233–239.

Cannon, M., Caspi, A., Moffitt, T.E., Harrington, H., Taylor, A., Murray, R.M., Poulton, R.,2002. Evidence for early-childhood, pan-developmental impairment specific toschizophreniform disorder: results from a longitudinal birth cohort. Arch. Gen.Psychiatry 59 (5), 449–456.

Caplan, R., 1994. Communication deficits in childhood schizophrenia spectrum disorders.Schizophr. Bull. 20, 671–683.

Carrell, P.L., 1982. Cohesion is not coherence. TESOL Q. 16 (4), 479–488.




Centre for Longitudinal Studies, 2013. Select ‘National Child Development Study’[Internet]. http://www.cls.ioe.ac.uk/.

Corcoran, R., Frith, C.D., 1996. Conversational conduct and the symptoms of schizo-phrenia. Cogn. Neuropsychiatry 1, 305–318.

Done, D.J., Johnstone, E.C., Frith, C.D., Golding, J., Shepherd, P.M., Crow, T.J., 1991. Com-plications of pregnancy and delivery in relation to psychosis in adult life: data fromthe British perinatal mortality survey sample. BMJ 302 (6792), 1576–1580.

Done, D.J., Crow, T.J., Johnstone, E.C., Sacker, A., 1994. Childhood antecedents of schizo-phrenia and affective illness: social adjustment at ages 7 and 11. BMJ 309 (6956),699–703.

Eaton, W.W., 1985. Epidemiology of schizophrenia. Epidemiol. Rev. 7 (1), 105.Frith, C.D., 2004. Schizophrenia and theory of mind. Psychol. Med. 34 (03), 385–389.Frith, C.D., Allen, H.A., 1988. Language disorders in schizophrenia and their implica-

tions for neuropsychology. In: Bebbington, P., McGuffin, P. (Eds.), Schizophrenia:The Major Issues. Heinemann, Oxford, UK, pp. 172–186.

Godbout, L., Doyon, J., 1995. Mental representation of knowledge following frontal-lobe or postrolandic lesions. Neuropsychologia 33, 1671–1696.

Gooding, D.C., Coleman, M.J., Roberts, S.A., Shenton, M.E., Levy, D.L., Erlenmeyer-Kimling, L., 2010. Thought disorder in offspring of schizophrenic parents: findingsfrom the New York high-risk project. Schizophr. Bull. 38 (2), 263–271.

Grice, H.P., 1969. Utterer's meaning and intention. Philos. Rev. 78 (2), 147–177.Griffith, J.J., Mednick, S.A., Schulsinger, F., Diderichsen, B., 1980. Verbal associative dis-

turbances in children at high risk for schizophrenia. J. Abnorm. Psychol. 89,125–131.

Griffith, P.L., Dastoli, S.L., Ripich, D.N., Nwakanma, O.N., 1985. Story grammar organiza-tion in story recall by learning disabled and nondisabled children. Ment. Retard.Learn. Disabil. Bull. 13 (2), 92–105.

Halliday, M.A.K., Hasan, R., 1976. Cohesion in English. Longman, London.Harvey, P.D., 1983. Speech competence in manic and schizophrenic psychoses: the

association between clinically rated thought disorder and cohesion and referenceperformance. J. Abnorm. Psychol. 92, 368–377.

Harvey, P.D., Weintraub, S., Neale, J.M., 1982. Speech competence of children vulnera-ble to psychopathology. J. Abnorm. Child Psychol. 10, 373–388.

Jablensky, A., Sartorius, N., Ernberg, G., Anker, M., Korten, A., Cooper, J.E., et al., 1992.Schizophrenia: Manifestations, incidence and course in different cultures: aWorld Health Organization ten-country study. Psychol. Med. Monogr. Suppl. 20,1–97.

Janowsky, J.S., Shimamura, A.P., Squire, L.R., 1989. Memory and metamemory: compari-sons between patients with frontal lobe lesions and amnesic patients. Psychobiology17, 3–11.

Kurcek, J., Duff, M.C., 2012. Intact discourse cohesion and coherence following bilateralventromedial prefrontal cortex. Brain Lang. 123, 222–227.

Langdon, R., Coltheart, M., Ward, P.B., Catts, S.V., 2002. Disturbed communication inschizophrenia: the role of poor pragmatics and poor mind-reading. Psychol. Med.32, 1273–1284.


Liles, B.Z., 1993. Narrative discourse in children with language disorders and childrenwith normal language: a critical review of the literature. J. Speech Hear. Res. 36,868–882.

Mar, R.A., 2004. The neuropsychology of narrative: story comprehension, story produc-tion and their interrelation. Neuropsychologia 42, 1414–1434.

McCreadie, R., 1982. The Nithsdale schizophrenia survey 1. Psychiatric and social hand-icaps. Br. J. Psychiatry 140, 582–586.

Parnas, J., Schulsinger, H., 1986. Continuity of formal thought disorder from childhoodto adulthood in a high-risk sample. Acta Psychiatr. Scand. 74, 246–251.

Purcell, S., Liles, B.Z., 1992. Cohesion repairs in the narratives of normal-language andlanguage disordered children: story structure, cohesion, and propositions. J. SpeechHear. Res. 35, 354–362.

Raffard, S., D'Argembeau, A., Lardi, C., Bayard, S., Boulenger, J.-P., Van der Linden, M.,2010. Narrative identity in schizophrenia. Conscious. Cogn. 19, 328–340.

Richardson, K., Calnan, M., Essen, J., Lambert, L., 1976. The linguistic maturity of11-year-olds: some analysis of the written compositions of children in the NationalChild Development Study. J. Child Lang. 3 (1), 99–115.

Rochester, S.R., Martin, J.R., 1979. Crazy Talk: A Study of the Discourse of SchizophrenicSpeakers. Plenum Press, New York, NY.

Roth, F.P., Speckman, N.J., 1986. Narrative discourse: spontaneously generated stories oflearning disabled and normally achieving students. J. Speech Hear. Disord. 51, 8–23.

Saavedra, J., 2010. Quantitative criteria of narrative coherence and complexity inpersons with paranoid schizophrenia. J. Nerv. Ment. Dis. 198 (5), 349–355.

Sass, L., 2003. Self disturbance in schizophrenia: hyperreflexivity and diminished self-affection. In: Kircher, T., David, A. (Eds.), The Self in Neuroscience and Psychiatry.Cambs Univ Press, Cambs. ISBN: 9780511072109.

Schiffman, J., Lam, C.W., Jiwatram, T., Ekstrom, M., Sorensen, H., Mednick, S., 2004.Perspective-taking deficits in people with schizophrenia spectrum disorders: aprospective investigation. Psychol. Med. 34, 1581–1586.

Schulz, J., Sundin, J., Leask, S., Done, D.J., 2012. Risk of adult schizophrenia and its rela-tionship to childhood IQ in the 1958 British birth cohort. Schizophr. Bull. 30. http://dx.doi.org/10.1093/schbul/sbs157 (Dec 2012).

Sperber, D., Wilson, D., 2002. Pragmatics, modularity and mindreading. Mind Lang. 17,3–23.

Tavano, A., Sponda, S., Fabbro, F., Perlini, C., Rambaldelli, G., Ferro, A., Cerruti, S., Tansell,M., Brambilla, P., 2008. Specific linguistic and pragmatic deficits in Italian patientswith schizophrenia. Schizophr. Res. 102, 53–62.

Tiernay, R.J., Mosenthal, J.H., 1983. Cohesion and textual coherence. Res. Teach. Engl.17, 215–229.

Watt, N.F., 1978. Patterns of childhood social development in adult schizophrenics.Arch. Gen. Psychiatry 35, 160–165.

Wing, J.K., Cooper, J.E., Sartorius, N., 1974. Measurement and Classification of PsychiatricSymptoms: An Instruction Manual for the PSE and Catego Program. Cambs UnivPress.


http://www.cls.ioe.ac.uk/

http://dx.doi.org/10.1093/schbul/sbs157


pragmatic use of language by children who develop schizophrenia in adult life

Documents