Mieke P. Ketelaars

Pragmatic Language Impairment and Associated Behavioural Problems.

BACKGROUND Specific language impairment (SLI) is diagnosed when a child shows isolated structural language problems. The diagnosis of pragmatic language impairment (PLI) is given to children who show difficulties with the use of language in context. Unlike children with SLI, these children tend to show relatively intact structural language skills while they do exhibit clear communicative deficits. There is hardly any research on the relationship between pragmatic competence and behavioural problems. Existing research suggests a strong relationship, but has only been executed on clinical SLI samples. Moreover, it is not known whether pragmatic language problems are related to specific types of behavioural problems. AIMS This study aims to clarify the incidence and nature of behavioural problems in children with PLI using a prognostic design in mainstream education. This design should provide valuable insights into the general relationship between PLI and various behavioural problems. METHODS & PROCEDURES Teachers completed the Childrens Communication Checklist (CCC) and the Strengths and Difficulties Questionnaire (SDQ) and provided additional data for a sample of 1364 children aged 4 years. OUTCOMES & RESULTS Within the community sample, pragmatic competence is highly correlated with behavioural problems. Pragmatic competence is a good predictor of behavioural problems, and once pragmatic competence is accounted for, structural language abilities do not predict behavioural problems. Children with pragmatic language impairment often show behavioural problems, largely of an externalizing nature. The most prominent problems are hyperactivity and the lack of prosocial behaviour, which reach clinical levels for this group. However, all problem levels are elevated compared with normally developing children. CONCLUSIONS & IMPLICATIONS Young children with PLI show a wide variety of behavioural problems. Early assessment of pragmatic competence may benefit early detection of children at risk of behavioural problems. Furthermore, due to the relationship between pragmatic competence, behavioural problems and possible underlying disorders such as autism and attention-deficit hyperactivity disorder (ADHD), early assessment of pragmatic competence may also provide an early marker for the detection of autism or ADHD.

Screening for pragmatic language impairment: The potential of the children's communication checklist

The present study examines the validity of the Dutch Childrens Communication Checklist (CCC) for children in kindergarten in a community sample, in order to assess the feasibility of using it as a screening instrument in the general population. Teachers completed the CCC for a representative sample of 1396 children at kindergarten level, taken from 53 primary schools in The Netherlands. The CCC was also completed for a clinical group consisting of children with SLI in special education. Reliability as measured with internal consistency scores was found to be good for the community sample. With regard to the construct validity, a five-factor second-order factor model was found when the pragmatic subscales were analysed, which provided a reasonable fit. Criterion validity as measured using the concordance between the CCC and teacher opinions was moderate. The children identified by the CCC as having Pragmatic Language Impairment (defined as scoring below the cut off of 132) were often characterized by the teachers as having social-emotional problems, language problems or combined problems. Comparison with a clinical SLI sample showed the pragmatically impaired children in the community sample to have a profile similar to that of the clinical group of children with PLI in special education. The main difference was visible in structural language problems, which were less severe for the PLI group in mainstream education. The results of this study suggest that screening for PLI is indeed possible using the CCC.

Assessment of theory of mind in children with communication disorders: role of presentation mode.

Children with communication disorders have problems with both language and social interaction. The theory-of-mind hypothesis provides an explanation for these problems, and different tests have been developed to test this hypothesis. However, different modes of presentation are used in these tasks, which make the results difficult to compare. In the present study, the performances of typically developing children, children with specific language impairments, and children with autism spectrum disorders were therefore compared using three theory-of-mind tests (the Charlie test, the Smarties test, and the Sally-and-Anne test) presented in three different manners each (spoken, video, and line drawing modes). The results showed differential outcomes for the three types of tests and a significant interaction between group of children and mode of presentation. For the typically developing children, no differential effects of presentation mode were detected. For the children with SLI, the highest test scores were consistently evidenced in the line-drawing mode. For the children with ASD, test performance depended on the mode of presentation. Just how the childrens non-verbal age, verbal age, and short-term memory related to their test scores was also explored for each group of children. The test scores of the SLI group correlated significantly with their short-term memory, those of the ASD group with their verbal age. These findings demonstrate that performance on theory-of-mind tests clearly depend upon mode of test presentation as well as the childrens cognitive and linguistic abilities.

Narrative competence and underlying mechanisms in children with pragmatic language impairment

This study investigated narrative competence in children with pragmatic language impairment (PLI) and the extent to which it is related to impairments in theory of mind and executive functioning (EF). Narrative competence was assessed using a retelling design in a group of 77 children with PLI and a control group of 77 typically developing children, aged 5. The children with PLI showed an overall poorer narrative competence as apparent in measures of narrative productivity, organization of content, and cohesion. Some of these differences could be attributed to language impairments. The remaining differences could be partly interpreted as pragmatic deficits. In typically developing children, narrative productivity skills were related to both theory of mind and EF, but only theory of mind explained unique variance once language ability was added to the model. In the PLI group, however, narrative productivity skills were solely related to EF, over and above language abilities. Organization of story content and cohesion were not related to any of the cognitive measures for either group. The results indicate that children with PLI show narrative deficits and that these deficits are related to EF.

Dynamics of the Theory of Mind construct: A developmental perspective

Theory of Mind (ToM) encompasses a wide variety of abilities, which develop during childhood. However, to date most ToM research has focused on the single concept of false-belief understanding, and examined ToM only in young children. Furthermore, there is a lack of implementation of a longitudinal design, which examines the dynamics of the ToM construct over several years. Our longitudinal study measured the abilities of a group of 5-year-old children (n = 77) in mainstream education during three consecutive years, on aspects of ToM related to emotion understanding and false-belief understanding. The results provide support for significant improvements in emotion understanding and false-belief understanding between the ages of 5 and 7. Whereas emotion attribution was already largely developed at age 5, more intricate aspects of emotion understanding, such as understanding display rules and understanding mixed emotions showed significant developments. Over the course of the years, children also showed an increasing awareness of false-belief understanding. In addition to the developmental growth, the different ToM aspects were found to be relatively stable over time. Correlations as well as predictive relations between emotion understanding and false-belief understanding could be identified. Finally, there was evidence for the role of language ability in the development of the ToM aspects under consideration. The results support the notion that ToM abilities measured at age 5 are not just a snapshot but provide a longer-term outlook as well.

Pragmatic Language Impairment

Pragmatic Language Impairment (PLI) has a long history of differing terms and definitions. Currently, it is known under the diagnostic label Social Communication Disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, Diagnostic and statistical manual of mental disorders. Fifth edition. American Psychiatric Publishing, Arlington, 2013). Its main symptoms are deficits in using communication for social purposes, an impaired ability to change communication to match context or the needs of the listener, difficulty following rules of conversation and storytelling, and difficulty understanding what is not explicitly stated. Due to a lack of clarity around the terminology and diagnostic criteria for PLI, there is still debate whether it is in fact a language disorder or an autism spectrum disorder, and whether PLI should be a separate diagnostic entity. As such, our understanding of PLI on the level of etiology, clinical profile, prognosis and treatment is limited. In addition, the absence of reliable, ecologically valid instruments to assess pragmatic functioning hampers progress in this regard, although recently there has been an increase in research into both diagnostic tools and potential interventions.

Social attention and autism symptoms in high functioning women with autism spectrum disorders

BACKGROUND Research has suggested a different, less visible, clinical manifestation of Autism Spectrum Disorders (ASD) in females. There is, however, limited research into possible underlying mechanisms explaining the female phenotype. AIMS This study investigates social attention in females with ASD. METHODS AND PROCEDURES 26 women diagnosed with ASD and 26 typical female controls were shown three video clips containing intense emotions. Social attention was assessed by measuring eye fixation patterns during the video clips. Autism symptoms were assessed using the informant reported Social Responsiveness Scale (SRS). OUTCOME AND RESULTS Results show normal time to first fixation to the face, but lower fixation duration to the face in women with ASD. Analyzing the visual patterns further, there were similar impairments in fixation to mouth, eyes and other facial areas. Relating social attention to autism symptoms revealed several significant correlations within the ASD group. CONCLUSIONS AND IMPLICATIONS Women with ASD show abnormalities in social attention and these abnormalities are related to level of autism symptoms. In contrast to other studies which investigate male dominated ASD samples, a hyperfocus to the mouth area could not be found.

Narrative competence in children with pragmatic language impairment: a longitudinal study

BACKGROUND Children with pragmatic language impairment (PLI) show impairments in the use of language in social contexts. Although the issue has been gaining attention in recent literature, not much is known about the developmental trajectories of children who experience pragmatic language problems. Since narrative competence is an important predictor of both academic and social success, evaluating narrative competence in children with PLI is deemed important. AIMS To examine the development of narrative competence of children with PLI compared with typically developing (TD) children using a prognostic longitudinal design. METHODS & PROCEDURES Using the Dutch adaptation of the Renfrew Bus Story Test, narrative competence was assessed at ages 5-7 for a group of 84 children with PLI and a group of 81 TD children. Groups were compared on measures of narrative productivity, organization of story content and cohesion. OUTCOMES & RESULTS Results showed an increase in narrative competence for both groups across most time points. The PLI group obtained lower scores on measures of narrative productivity and story content organization compared with their TD peers at all time points, but did not show more problems related to narrative cohesion. Most problems in the domain of narrative productivity and story content organization were shown to be independent of lower non-verbal intelligence. The developmental trajectory for the PLI group was largely similar to that of their TD peers, and showed a persistent developmental delay of approximately one year. Furthermore, qualitative differences were visible in the proportion of irrelevant T-units, which was consistently higher in the PLI group. The different narrative measures were found to be relatively stable over time. CONCLUSIONS & IMPLICATIONS The results of this study suggest that narrative difficulties of children identified as pragmatically impaired persist at least until middle childhood. The persistence of the measured developmental delay, combined with the finding of qualitative differences, support the view of PLI as a deficit, which is consistent with the addition of social communication disorder (SCD) to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Autismespectrumstoornissen: diagnostiek in neurocognitief perspectief

Autismespectrumstoornissen (ASS) worden gekenmerkt door problemen in de sociale interactie, problemen in de communicatie en beperkte en repetitieve interesses en gedragingen. Er is een groeiend besef van de genetische factoren en de neurobiologische problemen die aan het gedragsbeeld ten grondslag liggen. Het ontwikkelen van valide en betrouwbare instrumenten om de symptomen die bij autisme horen in beeld te brengen heeft tot positieve ontwikkelingen geleid op het gebied van vroegdiagnostiek. Tegelijkertijd heeft onderzoek zich gericht op onderliggende cognitieve mechanismen die het gedragsbeeld van autisme kunnen verklaren. Hoewel geen van de cognitieve verklaringskaders in staat is het fenotype van ASS volledig te verklaren, biedt neurocognitief onderzoek de mogelijkheid om een sterkte-zwakteanalyse te maken van het functioneren van individuen met ASS. Daarbij kunnen relatieve sterktes worden ingezet om voor zwakke vaardigheden te compenseren, of kan er gericht worden gewerkt aan het optimaliseren van de omgeving.