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autism Pragmatic language impairment without autism

Pragmatic languageimpairment without autismThe children in questionNICOLA BOTTINGU niversity of Manchester, UKGINA CONTI-RAMSDENU niversity of Manchester, UK371autism 1999 SAGE Publications and The National autistic Society,Vol 3(4) 371 396;0104381362-3613(199912)3:4 ABSTRACTThe borderlands of autism are of particular interest toresearchers and clinicians as we learn more about pervasive disordersand how to manage them. One group of children who have causedparticular controversy are those referred to as having semantic-prag-matic disorder or Pragmatic language impairment . The present articleexamines the profiles of 10 children (selected from a wider project onlanguage impairment ) who are definitely considered to have prag-matic impairments by their teachers, their speech and language ther-apists and the researchers and on the basis of scores from theChildren s Communication Checklist (CCC).

matic children to an autistic control group on theory of mind tasks. Other authors have also commented on their possible inclusion in the autistic

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Transcription of autism Pragmatic language impairment without autism

1 Pragmatic languageimpairment without autismThe children in questionNICOLA BOTTINGU niversity of Manchester, UKGINA CONTI-RAMSDENU niversity of Manchester, UK371autism 1999 SAGE Publications and The National autistic Society,Vol 3(4) 371 396;0104381362-3613(199912)3:4 ABSTRACTThe borderlands of autism are of particular interest toresearchers and clinicians as we learn more about pervasive disordersand how to manage them. One group of children who have causedparticular controversy are those referred to as having semantic-prag-matic disorder or Pragmatic language impairment . The present articleexamines the profiles of 10 children (selected from a wider project onlanguage impairment ) who are definitely considered to have prag-matic impairments by their teachers, their speech and language ther-apists and the researchers and on the basis of scores from theChildren s Communication Checklist (CCC).

2 These children are com-pared with each other and with children with more typical specificlanguage impairments (SLIs) in the wider study. The 10 children scharacteristics are also examined in terms of classification andwhether some might be better described using existing autistic spec-trum disorder terminology. Children with Pragmatic language impair-ment were all found to have developed first words earlier than the SLIgroup, but were more impaired than their peers in the areas of stereo-typed language , rapport and context. Social communication skills asmeasured by the CCC did not seem more impaired than in other chil-dren with SLI, but on the Harter scale peer interactions were rated assignificantly poorer. A preliminary comparison with autistic sympto-matology suggested that four of the 10 did have difficulties in this areaand might be better described as having autism or Asperger s should be addressed to:NICOLA BOTTING, Centre forthe Study of language Impairments, Centre for Educational Needs, School of Education,University of Manchester, Oxford Road, Manchester M13 9PL, UKkeywordscommunicationdisorders;pragmat iclanguageimpairmentIntroductionAs researchers become increasingly interested in classifying children withcommunication disorders more precisely, the difficulties in describing thespecific characteristics of different profiles of impairment have been high-lighted.

3 One particular group that has been the focus of much debate is thesubgroup of children described as having semantic- Pragmatic syndrome (Rapin and Allen, 1983; 1998), semantic- Pragmatic difficulties (Vanceand Wells, 1994) conversational disability (Conti-Ramsden and Gunn,1986), Pragmatic disability (McTear and Conti-Ramsden, 1992), seman-tic- Pragmatic disorder (SPD: Bishop and Rosenbloom, 1987) or morerecently Pragmatic language impairment (PLI: Bishop, 1998; Conti-Ramsden and Botting, in press).First, there is debate as to whether children with this type of im-pairment exist as a valid separate clinical group (Brook and Bowler, 1992;Gagnon et al., 1997). From a clinical perspective, children with primarypragmatic language impairments have been described as having super-ficially normal language development, unusual language constructions,difficulty using Pragmatic cues in conversation, difficulty in turn-takingand complex difficulties with comprehension (Bishop and Rosenbloom,1987; Rapin and Allen, 1987; McTear and Conti-Ramsden, 1992; Attwood,1998).

4 Thus, there is controversy as to whether in fact they should be diag-nosed instead as having high-functioning autism or Asperger syndrome(Gagnon et al., 1997). The characteristics of children classified by DSM-IV(American Psychiatric Association, 1994) as having pervasive developmen-tal disorders not otherwise specified (PDD-NOS) are also similar to thoseassociated with Pragmatic language impairment (Mahoney et al., 1997;Buitelaar and van der Gaag, 1998; Prior et al., 1998).Currently the term semantic- Pragmatic disorder is used (in Britain atleast) to refer to children who do notmeet a diagnosis for autism . However,Rapin and Allen originally used the term as a descriptive one, which appliesto children with specific language impairment , but mainlyto those withautism. This is highlighted recently in Rapin s (1996) update paper. Theterm Pragmatic language impairment (PLI) is very recent and representsan attempt to specify more precisely the relevant features of this clinicalgroup.

5 It is used in this article and in Bishop s (1998) work to replace theterm semantic- Pragmatic disorder for children without a group of children with Pragmatic difficulties but without autismdoes exist as a separate entity, the second debate centres around whetherthese children are more accurately classified as a subgroup of those with lan-guage impairment or those with more pervasive developmental disorders(see Boucher, 1998).There have been several suggestions that children withpragmatic language impairment are more similar to those with autism thanto peers with specific language impairment although the latter constitutes afundamentally heterogeneous group (Conti-Ramsden et al., 1997). Forexample, Shields et al. (1996) emphasize the similarity of semantic-prag- autism 3(4)372matic children to an autistic control group on theory of mind tasks. Otherauthors have also commented on their possible inclusion in the autisticspectrum (Bishop and Rosenbloom, 1987; Rapin, 1996; Boucher, 1998).

6 One of the major problems appears to be the subjective or clinicalnature of classifying children with Pragmatic language impairment (PLI).Standardized tests have in general failed to tap the key behaviours and dif-ficulties of this group (Botting et al., 1997). Different educational policiesand theoretical viewpoints have meant that, clinically and academically,professionals are in disagreement about which children do and do not havea primary Pragmatic language impairment . This has made the literature andresearch difficult to interpret, and poor at providing practical are disagreements about the level of structural language impairment (both expressively and receptively), about the degree of rigidity exhibitedand about the earlier history of these children, which cannot be exploredwithout some level of objective definition of the to date have used either clinical opinion ( Bishop andAdams, 1989; Kerbel et al.)

7 , 1996; Shields et al., 1996) or checklist data(Bishop, 1998) to define the samples. Others ( Vance and Wells, 1994)appear to have excluded children on the very variables that are of specificinterest (understanding semantic anomaly). This latter difficulty is also aproblem within the autism literature, in which children who are at themore subtle end of the autistic continuum are often excluded from specificresearch designs ( Gillberg and Gillberg, 1989).Third, there is discussion as to whether the terms semantic and prag-matic necessarily co-occur and whether it is useful to use the term seman-tic when referring to children in this category (Bishop, 1998). Much ofthe clinical discussion and confusion arises from the association betweensemantic problems and word-finding or word-naming , Bishop (1998) noted the absenceof low scores on a test of wordnaming in children with Pragmatic impairments.

8 Dockrell et al. (1998)found that 23 percent of children in language support services were ident-ified as having word-finding difficulties by speech and language therapists,but these errors were more associated with grammatical difficulties thanpragmatic ones. McGregor (1997) compared word-finding errors in agroup of young normally developing children and those with clinicallydefined word-finding difficulties. Few qualitative differences were foundbetween the groups, which may suggest that there is a delay, rather than adisorder, in word-finding skills in many children with specific studies suggest that the term semantic may falsely imply thatlexical semantic difficulties are a particular feature of this group. Othertypes of semantic disability have been less systematically & conti-ramsden: Pragmatic language373 However, some studies exploring semantic understanding, especially liter-ality and idiom comprehension, have shown that whilst children with PLIscore more poorly than those with specific language impairments, they arealso accurate the majority of the time (Bishop and Adams, 1989; Kerbeland Grunwell, 1998).

9 Present studyDespite the debate, children fitting the Pragmatic language impairmentdescription appear to form a significant minority within language units inEngland. In a recent study (Botting et al., 1998), we identified 53 out of 234children with major Pragmatic difficulties at both 7 and 8 years of age andthis figure does not take into account those not attending language , the difficulties of children with PLI have proved extremelydifficult not only to define but also to remediate, and many units havefound their turnover of such children to be considerably slower than thatof other language impaired pupils (Botting, 1998; Botting et al., 1998). Itis essential, therefore, for both theoretical and practical reasons thatresearch identifies and classifies the problems of children with so-called semantic- Pragmatic difficulties. Thus, whilst PLI continues to be confusedwith autism , it may also be difficult to differentiate it from receptive-expressive language impairments, with some clinicians believing thatpragmatic difficulties are purely a result of severe structural language diffi-culties.

10 For this reason, children with PLI in this study are compared sys-tematically with peers considered to have more typical specific languageimpairments (SLIs) of all seems logical to begin by identifying children who are at least clin-ically thought to have primary Pragmatic language difficulties. A recentstudy by the present authors which assessed over 240 children aged 7 8years in language units (Conti-Ramsden et al., 1997; Conti-Ramsden andBotting, 1999) found a number of children who appeared to have primarypragmatic language impairments according to teachers and speech and lan-guage therapists (n 53). A subset of children from the study also par-ticipated in a reliability and validity analysis of a new measure by Bishop(1998), the Children s Communication Checklist (CCC). In this secondstudy, two subgroups were revealed as being separate from children withtypical SLI, in that they showed a particular difficulty with the pragmaticelements of language .


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