Understanding the risks of social pragmatic deficits in post institutionalized internationally adopted (IA) children.

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This article was originally published in December 24, 2012 issue of Advance for Speech Language Pathologists and Audiologists under the title: “Adoption & Pragmatic Problems” (pp 6-9) 

Photo credits: Leonid Khavin

Cover Model: Bella Critelli

According to U.S. State Department, 233,934 children were adopted internationally between 1999-2011, with a majority 76 percent (or approximately 177,316) of these children being under 3 years of age.

To date a number of studies have come out about various aspects of these children’s language development, including but not limited to, rate of new language acquisition, patterns of typical vs. atypical language acquisition, as well as long-term language outcomes post-institutionalization.

While significant variability was found with respect to language gains and outcomes of internationally adopted children, a number of researchers found a correlation between age of adoption and language outcomes, namely, children adopted at younger ages (under 3 years of age) seem to present with better language/academic outcomes in the long-term vs. children adopted at older ages.1,2,3,4

Indeed, it certainly stands to reason that the less time children spend in an institutional environment, the better off they are in all areas of functioning (cognitive, emotional, linguistic, social, etc.). The longer the child stays in an institutional environment, the greater is the risk of greater delays, including a speech and language delay.

However, children adopted at younger ages, may also present with significant delays in select areas of functioning, many years post-adoption.

Less-Obvious Language Delays

It is important to realize not all language-based delays are readily obvious. From select studies we know some children adopted under age 2 often score appropriately on such major speech language tests as the Preschool Language Scale-4 (PLS-4) within 1 year post-adoption.2

Often these children are discharged from early intervention services and are not given any other language reassessments in preschool and elementary school unless there is evidence of major language issues (doing very poorly in classes, are poor readers, show emotional and behavioral disturbances, etc.). However, institutionalization can also significantly affect the child’s ability to relate and interact appropriately with others, though often this may manifest when the child is older.

From personal clinical observations, I can share in recent years I have assessed, and consulted about, a number of post-institutionalized internationally adopted children at 5 to 10 years post-adoption, who tested average to high average on standardized language testing batteries (e.g., CELF-4, CASL, OWLS, etc.) but who presented with significant pragmatic and social cognitive deficits, which interfered with their academic performance, as well as social interactions in and out of school environment.

For those speech-language professionals who provide assessment and intervention to post-institutionalized internationally adopted children, the above may seem unusual in the sense that most of us typically expect to see a cluster of language deficits (e.g., poor sentence formation, limited vocabulary, listening comprehension deficits, etc.) in conjunction with impaired social skills. We are also accustomed to seeing psychiatric or neurological diagnostic labels that explain the reasons behind impaired social pragmatic functioning in internationally adopted children.

Yet, interestingly, the children who ended up receiving treatment on my caseload were all assessed by a wide variety of specialized IA professionals such as psychiatrists, neurologists and psychologists who could not find any obvious neurological/psychiatric signs (e.g.., ASD, ADHD), which could support the presence of social pragmatic deficits as part of an underlying disorder.

A number of these children shared a common developmental profile: adoption took place when the children were under 16 months of age; no significant medical issues were reported or observed with the exception of mild speech-language delays, for which some children (but not all) qualified for EI services. No speech-language services were received post-EI. Functional communicative abilities were achieved within +/- one year, followed by steady further language acquisition.

Recognizing Challenging Behaviors

During the early school years (Kindergarten through 1st grade), these children received good grades and exhibited appropriate classroom performance. When the parental and professional concerns did emerge (in 1st and 2nd grades, though in one case in middle school), these social pragmatic difficulties were originally thought to be challenging behaviors.

When asked to describe how these behaviors manifested, parents and teachers used expressions such as “immature behaviors,” “emotional aloofness,” “shyness,” tendency to ignore presented directions,” tendency to “follow own agenda,” inappropriate “acting out,” “disregard” for social rules and conventions, “lack” of sympathy and empathy, “lack of emotion recognition” along with similar terms, which described these children’s difficulties.

School-based child team referrals and subsequent administration of standardized language tests, focused on receptive and expressive language alone, and did not yield any definitive results, except for a host of “external” referrals to psychologists and psychiatrists. Though merited at the time, these referrals did not successfully resolve the issue of these children’s linguistically based social cognitive deficits.

Consequently, I received a number of referrals for a second opinion from various mental health professionals specializing in international adoptions because one of my areas of specialty is assessment and treatment of language-based social pragmatic skills in children with confirmed or suspected emotional and psychiatric disturbances.

Social Pragmatic Deficits

Formal and informal social pragmatic skills assessments of these children revealed some common difficulties, which included: inappropriate interpretation of social situations, events and contexts, poor ability to create and convey messages to different audiences, poor ability to interpret facial expressions, body language and gestures, profound perspective taking deficits, poor initiation of social interaction, poor comprehension of age-level abstract and inferential information, persistent missing of “the big picture,” and poor peer relatedness. One child even presented with a severe difficulty labeling and identifying basic emotions of self and others, despite possessing a high average IQ, and no signs and symptoms of ASD or Asperger’s (as two psychiatrists ruled out).

Interestingly, despite being labeled as “shy” or “problem behavior” kids, all of the children presented as related, compliant and cooperative during their respective reassessments, as well as during previous speech-language and/or psychological testing. Thus, when judged by their adaptive behavior alone, it appeared as though their behavior and social skills were appropriate. However, after they given specific problem-solving and social language tasks (informal and formal) and were observed in social settings with peers, it quickly became apparent their deficits in realm of social pragmatics were quite pervasive.

Due to the narrowness of the deficits in question, identification of isolated social pragmatic difficulties is problematic without a comprehensive social pragmatic assessment, since post-institutionalized internationally adopted children with less obvious social pragmatic deficits are often at-risk for misdiagnosis, overmedication and denial of appropriate service provision.

Clinicians who are asked to assess internationally adopted children many years post-adoption are encouraged to conduct careful observations of these children in social situations. They should ask their parents to fill out detailed questionnaires regarding their social functioning, as well as to provide these children with a number of formal and informal testing tasks that would fully tap into their social pragmatic language functioning in order to create a comprehensive remediation plan that would successfully address specific deficit areas.

References:

  •  Botting, N., & Conti-Ramsden, G. (1999). Pragmatic language impairment without autism: The children in question. Autism, 3, 371–396.
  • Glennen, S. & Masters, G. (2002). Typical and atypical language development in infants and toddlers adopted from Eastern Europe. American Journal of Speech-LanguagePathology, 44, 417-433
  • Glennen, S., & Bright, B. J. (2005). Five years later: Language in school-age internationally adopted children. Seminars in Speech and Language, 26, 86-101.
  • Glennen, S (2009) Speech and Language Guidelines for Children Adopted from Abroad at Older Ages.  Topics in language Disorders 29, 50-64.
  • Intercountry Adoption Bureau of Consular Affairs US Department of State Retrieved on Jul 29, 2011  from  http://adoption.state.gov/about_us/statistics.php
  • 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.
  • Krakow, R.A., & Roberts, J. (2003).  Acquisition of English vocabulary by young Chinese adoptees.  Journal of Multilingual Communication Disorders. 1(3), 169-176.
  • Roberts, J. & Krakow, R. (2003). Language outcomes for preschool children adopted from China as infants and toddlers. Journal of Multilingual Communication Disorders, 1 (3), 177-183.
  • Scott, K., Roberts, J., & Glennen, S. (2011). How well do children who are internationally adopted acquire language? A meta-analysis. Journal of Speech, Language, & Hearing Research54, 1-17
  • Winner, Michelle Garcia (2007). Thinking about You, Thinking about Me. 2nd Ed. Think Social Publishing Inc. San Diego, CA.
  • Winner, Michelle Garcia (2008). Think Social: A Social Thinking Curriculum for School-Age Students. 2nd Ed. Think Social Publishing Inc. San Diego, CA. (supplement to above book)

cite as: Elleseff, T (2012, Dec 24) Understanding the risks of social pragmatic deficits in post institutionalized internationally adopted children. Published in Advance for Speech Language Pathologists and Audiologists. Pp 6-9.

3 Responses to “Understanding the risks of social pragmatic deficits in post institutionalized internationally adopted (IA) children.”

  1. natalieslp1 January 21, 2013 at 9:41 am #

    Tatyana, just read your article. Great job! Social pragmatic area is so frequently under tested, overlooked and ignored. This is great as you looked at a select population of kids. Interesting read. Looking forward to reading more.

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