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What are social pragmatic language deficits and how do they impact international adoptees years post adoption?

What are social pragmatic language deficits and how do they impact international adoptees years post adoption?

Tatyana Elleseff MA CCC-SLP

Scenario:   John is a bright 11 year old boy who was adopted at the age of 3 from Russia by American parents. John’s favorite subject is math, he is good at sports but his most dreaded class is language arts. John has trouble understanding abstract information or summarizing what he has seen, heard or read. John’s grades are steadily slipping and his reading comprehension is below grade level. He has trouble retelling stories and his answers often raise more questions due to being very confusing and difficult to follow. John has trouble maintaining friendships with kids his age, who consider him too immature and feel like he frequently “misses the point” due to his inability to appropriately join play activities and discussions, understand non-verbal body language, maintain conversations on age-level topics, or engage in perspective taking (understand other people’s ideas, feelings, and thoughts). John had not received speech language services immediately post adoption despite exhibiting a severe speech and language delay at the time of adoption. The parents were told that “he’ll catch up quickly”, and he did, or so it seemed, at the time. John is undeniably bright yet with each day he struggles just a little bit more with understanding those around him and getting his point across. John’s scores were within normal limits on typical speech and language tests administered at his school, so he did not qualify for school based speech language therapy. Yet John clearly needs help.

John’s case is by no means unique. Numerous adopted children begin to experience similar difficulties; years post adoption, despite seemingly appropriate early social and academic development. What has many parents bewildered is that often times these difficulties are not glaringly pronounced in the early grades, which leads to delayed referral and lack of appropriate intervention for prolonged period of time.

The name for John’s difficulty is pragmatic language impairment, a diagnosis that has been the subject of numerous research debates since it was originally proposed in 1983 by Rapin and Allen. 

So what is pragmatic language impairment and how exactly does it impact the child’s social and academic language abilities? 

In 1983, Rapin and Allen proposed a classification of children with developmental language disorders. As part of this classification they described a syndrome of language impairment which they termed ‘semantic–pragmatic deficit syndrome’. Children with this disorder were described as being overly verbose, having poor turn–taking skills, poor discourse and narrative skills as well as having difficulty with topic initiation, maintenance and termination. Over the years the diagnostic label for this disorder has changed several times, until it received its current name “pragmatic language impairment” (Bishop, 2000).

Pragmatic language ability involves the ability to appropriately use language (e.g., persuade, request, inform, reject), change language (e.g., talk differently to different audiences, provide background information to unfamiliar listeners, speak differently in different settings, etc) as well as follow conversational rules (e.g., take turns, introduce topics, rephrase sentences, maintain appropriate physical distance during conversational exchanges, use facial expressions and eye contact, etc) all of which culminate into the child’s general ability to appropriately interact with others in a variety of settings.

For most typically developing children, the above comes naturally. However, for children with pragmatic language impairment appropriate social interactions are not easy. Children with pragmatic language impairment often misinterpret social cues, make inappropriate or off-topic comments during conversations, tell stories in a disorganized way, have trouble socially interacting with peers, have difficulty making and keeping friends, have difficulty understanding why they are being rejected by peers, and are at increased risk for bullying.

So why do adopted children experience social pragmatic language deficits many years post adoption? 

Well for one, many internationally adopted children are at high risk for developmental delay because of their exposure to institutional environments. Children in institutional care often experience neglect, lack of language stimulation, lack of appropriate play experiences, lack of enriched community activities, as well as inadequate learning settings all of which has long lasting negative impact on their language development including the development of their pragmatic language skills (especially if they are over 3 years of age). Furthermore, other, often unknown, predisposing factors such as medical, genetic, and family history can also play a negative role in pragmatic language development, since at the time of adoption very little information is known about the child’s birth parents or maternal prenatal care.

Difficulty with detection as well as mistaken diagnoses of pragmatic language impairment 

Whereas detecting difficulties with language content and form is relatively straightforward, pragmatic language deficits are more difficult to detect, because pragmatics are dependent on specific contexts and implicit rules. While many children with pragmatic language impairment will present with poor reading comprehension, low vocabulary, and grammar errors (pronoun reversal, tense confusion) in addition to the already described deficits, not all the children with pragmatic language impairment will manifest the above signs. Moreover, while pragmatic language impairment is diagnosed as one of the primary difficulties in children on autistic spectrum, it can manifest on its own without the diagnosis of autism. Furthermore, due to its complicated constellation of symptoms as well as frequent coexistence with other disorders, pragmatic language impairment as a standalone diagnosis is often difficult to establish without the multidisciplinary team involvement (e.g., to rule out associated psychiatric and neurological impairment).

It is also not uncommon for pragmatic language deficits to manifest in children as challenging behaviors (and in severe cases be misdiagnosed due to the fact that internationally adopted children are at increased risk for psychiatric disorders in childhood, adolescence and adulthood). Parents and teachers often complain that these children tend to “ignore” presented directions, follow their own agenda, and frequently “act out inappropriately”. Unfortunately, since children with pragmatic language impairment rely on literal communication, they tend to understand and carry out concrete instructions and tasks versus understanding indirect requests which contain abstract information. Additionally, since perspective taking abilities are undeveloped in these children, they often fail to understand and as a result ignore or disregard other people’s feelings, ideas, and thoughts, which may further contribute to parents’ and teachers’ beliefs that they are deliberately misbehaving.

Due to difficulties with detection, pragmatic language deficits can persist undetected for several years until they are appropriately diagnosed. What may further complicate detection is that a certain number of children with pragmatic language deficits will perform within the normal range on typical speech and language testing. As a result, unless a specific battery of speech language tests is administered that explicitly targets the identification of pragmatic language deficits, some of these children may be denied speech and language services on the grounds that their total language testing score was too high to qualify them for intervention.

How to initiate an appropriate referral process if you suspect that your school age child has pragmatic language deficits? 

When a child is presenting with a number of above described symptoms, it is recommended that a medical professional such as a neurologist or a psychologist be consulted in order to rule out other more serious diagnoses. Then, the speech language pathologist can perform testing in order to confirm the presence of pragmatic language impairment as well as determine whether any other linguistically based deficits coexist with it. Furthermore, even in cases when the pragmatic language impairment is a secondary diagnosis (e.g. Autism) the speech language pathologist will still need to be involved in order to appropriately address the social linguistic component of this deficit.

To obtain appropriate speech and language testing in a school setting, the first step that parents can take is to consult with the classroom teacher. For the school age child (including preschool and kindergarten) the classroom teacher can be the best parental ally. After all both parents and teachers know the children quite well and can therefore take into account their behavior and functioning in a variety of social and academic contexts. Once the list of difficulties and inappropriate behaviors has been compiled, and both parties agree that the “red flags” merit further attention, the next step is to involve the school speech language pathologist (make a referral) to confirm the presence and/or severity of the impairment via speech language testing.

When attempting to confirm/rule out pragmatic language impairment, the speech language pathologist has the option of using a combination of formal and informal assessments including parental questionnaires, discourse and narrative analyses as well as observation checklists.

Below is the list of select formal and informal speech language assessment instruments which are sensitive to detection of pragmatic language impairment in children as young as 4-5 years of age.

1. Children’s Communication Checklist-2 (CCC–2) (Available: Pearson Publication)
2. Test of Narrative Development (TNL) (Available: Linguisystems Publication)
3. Test of Language Competence Expanded Edition (TLC-E) (Available: Pearson Publication)
4. Test of Pragmatic Language-2 (TOPL-2) (Available: Linguisystems Publication)
5. Social Emotional Evaluation (SEE) (Available: Super Duper Publication)
6. Dynamic Informal Social Thinking Assessment (www.socialthinking.com)
7. Social Language Development Test -Elementary (SLDT-E) (Available: Linguisystems Publication)
8. Social Language Development Test -Adolescent (SLDT-A) (Available: Linguisystems Publication)

It is also very important to note that several formal and informal instruments and analyses need to be administered/performed in order to create a complete diagnostic picture of the child’s deficits.

When to seek private pragmatic language evaluation and therapy services?

Unfortunately, the process of obtaining appropriate social pragmatic assessment in a school setting is often fraught with numerous difficulties. For one, due to financial constraints, not all school districts possess the appropriate, up to date pragmatic language testing instruments.

Another issue is the lack of time. To administer comprehensive assessment which involves 2-3 different assessment instruments, an adequate amount of time (e.g., 2+ hours) is needed in order to create the most comprehensive pragmatic profile for the child. School based speech language pathologists often lack this valuable commodity due to increased case load size (often seeing between 45 to 60 students per week), which leaves them with very limited time for testing.

Further complicating the issue are the special education qualification rules, which are different not just from state to state but in some cases from one school district to the next within the same state. Some school districts strictly stipulate that the child’s performance on testing must be 1.5-2 standard deviations below the normal limits in order to qualify for therapy services.
But what if the therapist is not in possession of any formal assessment instruments and can only do informal assessment?

And what happens to the child who is “not impaired enough” (e.g., 1 SD vs. 1.5 SD)?

Consequently, in recent years more and more parents are opting for private pragmatic language assessments and therapy for their children.

Certainly, there are numerous advantages for going via the private route. For one, parents are directly involved and directly influence the quality of care their children receive.

One advantage to private therapy is that parents can request to be present during the evaluation and therapy sessions. As such, not only do the parents get to understand the extent of the child’s impairment but they also learn valuable techniques and strategies they can utilize in home setting to facilitate carryover and skill generalization (how to ask questions, provide choices, etc).

Another advantage is the provision of individual therapy services in contrast to school based services which are generally attended by groups as large as 4-5 children per session. Here, some might disagree and state that isn’t the point of pragmatic therapy is for the child to practice his/her social skills with other children?

Absolutely! However, before a skill can be generalized it needs to be taught! Most children with pragmatic language impairment initially require individual sessions, in some of which it may be necessary to use drill work to teach a specific skill. Once the necessary skills are taught, only then can children be placed into social groups where they can practice generalizing their skills. Moreover, many of these children greatly benefit from being in group or play settings with typical peers and/or sibling tutors who may facilitate the generalization of the desired skill more naturally, all of which can be arranged within private therapy settings.

Yet another advantage to obtaining private therapy services is that there are some private clinics which are almost exclusively devoted to teaching social pragmatic communication and which offer a variety of therapeutic services including individual therapy, group therapy and even summer camps that target the improvement of pragmatic language and social communication skills.

The flexibility offered by private therapy is also important if a parent is seeking a specific social skills curriculum for their child (e.g., “Socially Speaking”) or if they are interested in social skill training that is based on the methods of specific researchers/authors (e.g., Michelle Garcia Winner MACCC-SLP; Dr. Jed Baker PhD, etc), which may not be offered by their child’s school.

There are many routes open for parents to pursue when it comes to their child’s pragmatic language assessment and intervention. However, the first step in that process is parental education!

To learn more about pragmatic language impairment please visit the ASHA website at www.asha.org and type in your query in the search window located in the upper right corner of the website. To find a professional specializing in assessment and treatment of pragmatic language disorders in your area please visit http://asha.org/proserv/.

References

Adams, C. (2001). “Clinical diagnostic and intervention studies of children with semantic-pragmatic language disorder.” International Journal of Language and Communication Disorders 36(3): 289-305.

Bishop, D. V. (1989). “Autism, Asperger’s syndrome and semantic-pragmatic disorder: Where are the boundaries?” British Journal of Disorders of Communication 24(2): 107-121.

Bishop, D. V. M. and G. Baird (2001). “Parent and teacher report of pragmatic aspects of communication: Use of the Children’s Communication Checklist in a clinical setting.” Developmental Medicine and Child Neurology 43(12): 809-818.

Botting, N., & Conti-Ramsden, G. (1999). Pragmatic language impairment without autism: The children in question. Autism, 3, 371–396.[

Brackenbury, T., & Pye, C. (2005). Semantic deficits in children with language impairments: Issues for clinical assessment. Language, Speech, and Hearing Services in Schools, 36, 5–16.

Burgess, S., & Turkstra, L. S. (2006). Social skills intervention for adolescents with autism spectrum disorders: A review of the experimental evidence. EBP Briefs, 1(4), 1–21.

Camarata, S., M., and T. Gibson (1999). “Pragmatic Language Deficits in Attention-Deficit Hyperactivity Disorder (ADHD).” Mental Retardation and Developmental Disabilities 5: 207-214.

Ketelaars, M. P., Cuperus, J. M., Jansonius, K., & Verhoeven, L. (2009). Pragmatic language impairment and associated behavioural problems. International Journal of Language and Communication Disorders, 45, 204–214.

Ketelaars, M. P., Cuperus, J. M., Van Daal, J., Jansonius, K., & Verhoeven, L. (2009). Screening for pragmatic language impairment: The potential of the Children’s Communication Checklist. Research in Developmental Disabilities, 30, 952–960.

Miniscalco, C., Hagberg, B., Kadesjö, B., Westerlund, M., & Gillberg, C. (2007). Narrative skills, cognitive profiles and neuropsychiatric disorders in 7-8-year-old children with late developing language. International Journal of Language and Communication Disorders, 42, 665–681.
Rapin I, Allen D (1983). Developmental language disorders: Nosologic considerations. In U. Kirk (Ed.), Neuropsychology of language, reading, and spelling (pp. 155–184). : Academic Press.

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How to select the right speech language pathologist for your adopted child?


How to select the right speech language pathologist for your adopted child?

You have decided to consult a private speech language pathologist because of concerns over your adopted child’s developing speech and language. But how do you choose the right one? There are many speech therapists out there and not all of them are alike in experience and skills. On top of it all, you are also looking for a bilingual therapist, one who is not only proficient in your child’s native language but is also knowledgeable regarding the speech and language issues of international adoptees. That is not an easy decision to make, especially for many parents who until now have not had any direct contact with a speech language pathologist.
Not to worry, below is a list of simple guidelines designed to assist you in the right therapist selection.

Let’s begin with something basic: educational and professional credentials. A speech language pathologist must possess a Master’s Degree (or its equivalent) from a reputable academic institution of higher learning. They must also have a Certificate of Clinical Competence from the American Speech Language Hearing Association as well as an appropriate licensure from the state in which they maintain their practice. Additionally, it is highly recommended that they have Bilingual Certification as it indicates that they have completed the necessary academic coursework and are proficient in the issues surrounding normal and disordered speech-language acquisition of bilingual children in dual languages.

Now we are ready to proceed to experience. Here its gets a little tricky. The traditional approach: “I want the therapist with a gazillion years of experience” is just not going to be all that useful. It can’t be just any experience; it has to be the right experience! After all do you really want a therapist with 30 years of experience in exclusively treating articulation deficits when your child needs help with feeding and swallowing or with developing augmentative/alternative communication?

It is important to choose a therapist who has a rich and varied experience from multiple settings, total years of experience may not be as important as the qualitative value of that experience. A good therapist has probably spent a considerable portion of his/her time in a variety of settings from schools and early intervention agencies to hospitals and rehabilitation clinics. As the result of working in these diverse environments that therapist is much more likely to come up with innovative ideas and solutions to your child’s problems as opposed to just using the same old remediation strategies that they have learned way back then. It is also a good idea to inquire regarding the areas of specialization of the therapist in order to find out whether he/she has successfully treated children with similar problems to your child’s.

Typically, private speech language pathologists who maintain some type of pediatric hospital affiliation (e.g. per diem or part-time employees) are up to date regarding the current methodologies, which they apply to practice on daily basis. The reasons for that are twofold:

Speech departments in hospitals deal with diverse caseloads, with patients ranging in ages, diagnoses (some of which can be quite unusual), and levels of severity. In an average inpatient department staff SLP’s are expected to carry caseloads of 12-16 patients per day.
In order to keep up with the caseload diversity and with the latest treatment trends, hospitals require these SLP’s to actively take professional development courses in order to provide their patients with the best quality of care.
This brings us to another important consideration: professional development. To maintain their state licensure and national certification all therapists are required to take professional education courses in order to stay up to date with all the relevant research and new treatments developed in our field. The minimum requirement is to accumulate 30 professional education hours every 3 years whether by attending courses in person, taking them online through qualified providers, or by conducting workshops and presenting at conferences. Professional development provides the speech therapists with an opportunity to use evidence based techniques supported and tested by research to treat a variety of communication disorders. Consequently, when selecting your therapist it is important to find out just how up to date are they on the current treatment methods and methodologies pertaining to your child speech and language deficits. You can always find out this information by politely questioning the therapist regarding their background and “resume highlights.”

It is also important to find out whether you understand and agree with the therapist’s methods and approaches. For example, if your child is a toddler, it probably does not make sense for him/her to spend most sessions doing worksheets and drills when he/she needs to be engaged in play based, child centered therapy. Don’t be intimidated by the therapist’s credentials and your lack of knowledge, if something they said doesn’t make sense, ask follow up questions and/or look up pertinent information online. While you should not use the internet to diagnose your child’s problems, it can be used as a valuable learning tool to look up information and to share ideas with other parents who experience similar difficulties.

Now that we have specified general selection criteria, let’s talk about how to initiate your search for the right SLP. The best way is again to go online. Start your search by going to the ASHA website and clicking on the ‘Find Professional Button’ located in the top of the page and then follow the instructions on the screen. Fill out your search criteria carefully but don’t be too specific. For example, don’t look for a Russian speaking SLP in Blue Creek, California as you will probably not find one. Instead try typing in the first 3 digits of your zipcode or your state of residence (if it’s small enough) and don’t forget to specify the language of the practitioner. That will get you the optimum results.

Once you have located several candidates, you can narrow down the search by trying to learn something about them online. Google the clinician’s name (or the name of their practice) to see whether they have their own website, have written any articles or have been profiled by any organizations. To make sure that your practitioner’s licensure is up to date, visit your state’s speech language accreditation website and type in the last name of the professional. Typically, a window will pop up listing the therapists’ names alphabetically, find the one you are looking for and check if their license is active. Finally, armed with your research, create a list of questions that you might have for the practitioners and start making phone calls. Find out all the pertinent information and don’t forget to ask about rates which may differ depending on what services the practitioner is providing.

Please note that many private practitioners refuse to deal with insurance companies directly due to the hassle of multiclient billing as well as extended wait for reimbursement. They will instead provide you with a letter for your insurance company, containing the necessary diagnosis and treatment codes, incurred fees as well as a brief description of services provided, and will expect you to apply for reimbursement on your own.

Now that we have gone over the selection process in some detail, please keep in mind that you can always learn more information on this and any other speech pathology related topic by visiting the ASHA website and clicking on the ‘Public’ tab located at the top of the screen.

Best of luck in your search and happy hunting!

Useful websites:
Find a Professional SLP on the ASHA website: http://www.asha.org/proserv/
State Contacts & Licensure Requirements: http://www.asha.org/about/legislation-advocacy/state/