what is pragmatic language impairment?

Dr Courtenay Frazier NorburyRALLI

Royal Holloway, University of London

pragmatic difficulties:

difficulties using and understanding language in context

• context is important because:– most of what we say is ambiguous

– most of what we intend to communicate is not explicitly stated

multiple meanings

“the fish is ready to eat”

I’ll have the steak.

inference

what I say:

• time to go to the shops.

• remember it’s wet outside.

what I mean:

• we are going outside• you need to get ready• it is still raining• make sure you put on

a waterproof jacket and your wellington boots

• for some children, problems using language in context may be more pronounced than problems with more basic aspects of language such as vocabulary and grammar

• these children may be referred to as having ‘pragmatic language impairment’; ‘semantic-pragmatic disorder’ or ‘social communication disorder’

origins of PLI: “semantic-pragmatic disorder”

• Rapin and Allen (1982)– semantic-pragmatic deficit syndrome used as

descriptive term– communicative profile more often seen in autistic

disorder, but could occur in other developmental populations, including SLI

• Bishop and Edmundson (1987)– semantic-pragmatic disorder used as a diagnostic

term– given to children with communicative profiles typical

of autistic disorder who did not meet full diagnostic criteria for autism

Semantic-pragmatic Syndrome/disorder: clinical descriptions (Rapin 1996)

• Phonology and syntax unimpaired

• Verbose

• Comprehension deficits for connected speech

• Atypical word choices

• Poor conversation skills

• Poor topic maintenance

• Answering beside the point of a question

terminology: move from semantic-pragmatic disorder to pragmatic language impairment

(PLI)• Conti-Ramsden et al (1997) investigated the

communication profiles of 7-year-olds in language units in the UK– sub-group scored within normal limits on

standard language measures, including those tapping semantic skills

– same group were described by teachers and clinicians as having significant pragmatic impairments

• note that pragmatic difficulties are not often picked up on standardised tests

terminology: move from semantic-pragmatic disorder to pragmatic language impairment

(PLI)

• Bishop (1998) developed the Children’s Communication Checklist (CCC) as a standard measure of pragmatic impairment in clinically referred populations– items tapping lexical-semantic abilities did not

differentiate those children thought to have pragmatic impairments from cases of more typical SLI

thus…

• semantic and pragmatic impairments do not necessarily go hand in hand

• significant numbers of children in language units (approx. 30%) have pragmatic language difficulties

• “diagnosis” dependent on child’s everyday communication skill rather than standardised tests (see Adams, 2002 for more about diagnosis).

is PLI a euphemism for autism?

• considerable academic and clinical debate about the status of this ‘disorder’– one view: PLI is just another word for autism– another view: PLI represents the middle

ground between SLI and autism– and finally: PLI is descriptive not diagnostic

Bishop & Norbury (2002)

• Children aged 6 – 12

• Recruited from specialist schools and units– 31 considered PLI (low scores on Children’s

Communication Checklist)– 19 typical SLI (high scores on Children’s

Communication Checklist)

• None of the children had received a formal diagnosis of autism

Bishop & Norbury (2002)

Three scenarios:

1. All children with PLI are autistic

2. PLI don’t meet criteria for autism, but do for atypical autism or PDDNOS

3. PLI can be found in non-autistic children

Diagnostic Tools for Autism

• Autistic Diagnostic Interview with parents (ADI)– Focus largely on early behaviour and development,

but some current functioning as well

• Autistic Diagnosis Observation Schedule (ADOS)– Focus on current behaviour only

• Social Communication Questionnaire (SCQ)– 40 items completed by parents, focus primarily on

early behaviours

PDDNOS= pervasive developmental disorder not

otherwise specified

used to refer to child with some autistic features who does not meet full criteria

(other terms: atypical autism, autistic spectrum disorder)

If scoring above threshold on 2 out of 3 domains of autistic triad.

How many meet criteria for autism?

autistic PDDNOS none

autistic

PDDNOS

none

ADOS-G

ADI/SCQ

children from PLI group

How many meet criteria for autism?

autistic PDDNOS none

autistic

PDDNOS

none

ADOS-G

ADI/SCQ

children from SLI-T group

Bishop & Norbury (2002)

Three scenarios:

1. All children with PLI are autistic

2. PLI don’t meet criteria for autism, but do for atypical autism or PDDNOS

3. PLI can be found in non-autistic children

x

x

√

Non-autistic children with PLI• tended to use more stereotyped language

and abnormal intonation than children with more ‘typical’ language impairment, but…– were interested in being ‘social’ (though

question how reciprocal interaction is)– very sociable and talkative– used non-verbal as well as verbal

communication– excessive interests or repetitive behaviours

were not a feature

diagnostic status of PLI depends on diagnostic criteria for autism spectrum disorder

• more importantly, pragmatic deficits are seen in children with AND without impairments in structural aspects of language (i.e. vocabulary and grammar)

• pragmatic deficits that aren’t picked up on formal tests may be evident in social interactions

intervention

• there is evidence that interventions targeting pragmatic language skills are effective (Adams et al. 2012)

• see the Social Communication Intervention Project (SCIP) for details:

• http://www.psych-sci.manchester.ac.uk/scip/

recommended readings:

• Adams C. (2002). Practitioner review: the assessment of language pragmatics. Journal of Child Psychology and Psychiatry, 43( 8), 973-87.

• Adams, C., Lockton, E., Freed, J., Gaile, J., Earl, G., McBean, K. , Nash, M., Green, J., Vail, A. & Law, J. (2012). The Social Communication Intervention Project: a randomised controlled trial of the effectiveness of speech and language therapy for school-age children who have pragmatic and social communication problems with or without autism spectrum disorder. International Journal of Language and Communication Disorders, 47(3), 233-244.

• Bishop DVM, Norbury CF (2002), ” Exploring the borderlands of autistic disorder and specific language impairment: A study using standardised diagnostic instruments “, Journal of Child Psychology and Psychiatry. 43: 917-929.Bishop,

• Bishop D et al. (2008). Autism and diagnostic substitution: Evidence from a study of adults with a history of developmental language disorder. Developmental Medicine and Child Neurology, 50, 341-345.

• Conti-Ramsden,G., Crutchley,A., Botting,N. (1997). The extent to which psychometric tests differentiate subgroups of children with SLI. Journal of Speech, Language, and Hearing Research 40, 765-777.

• Rapin, I. (1996). Preschool children with inadequate communication: developmental language disorder, autism, low IQ. Clinics in developmental medicine No. 139. Mac Keith Press, London, p 56-97.