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IT’S YOUR TURN: TAKING THE MYSTERY
OUT OF PRAGMATIC LANGUAGE
PRAGMATIC LANGUAGE
Heather L. Balog, Ph.D., CCC-SLP
Balog Speech & Language Center, PLLC
Plymouth, MI
heather.balog@balogspeechlang.com
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Taxonomy of Language (Lahey, 1988)
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Pragmatic Language Disorders
■ Who are the children with pragmatic language impairment?
Content
■ Here is a possible, but not an all inclusive list, from the literature:
– Autism Spectrum Disorders
– Williams Syndrome
– Fragile X Syndrome
– Second Language Learners
– General Speech and Language Impairment
– Attention Deficit and/or Attention Deficit/Hyperactivity Disorder
– Learning Disability
Form
Use
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DSM-V changes in Autism Definition
Autism Spectrum Disorder
■ DSM-IV (2000) (relevant 1994-2012) allowed for several categories of disorder:
– Autistic Disorder
– Asperger’s Disorder
– Rett’s Disorder
– Childhood Disintegrative Disorder
– Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS)
■ Deficits in social communication and social interaction (3 of 3
symptoms required):
– Deficits in social-emotional reciprocity
– Deficits in nonverbal communicative behaviors used for
social communication
– Deficits in developing and maintaining relationships
appropriate to developmental level
■ DSM-V (2013) allows for one disorder category:
– Autism Spectrum Disorder
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Autism Spectrum Disorder
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(DSM-V, 2013)
■ What is missing from DSM-V behavior/symptom
description?
■ Restricted, repetitive patterns of behavior, interests or activities (at least 2 of
4 symptoms):
– Stereotyped or repetitive speech, motor movements, or use of objects
– Excessive adherence to routines, ritualized patterns of verbal or
nonverbal behavior, or excessive resistance to change
– Highly restricted, fixated interests that are abnormal in intensity or
focus
– Hyper- or hypo-reactivity to sensory input or unusual interest in sensory
aspects of environment
H. L. Balog - ICCD 4.7.16 Pediatric Pragmatic Language
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Autism Spectrum Disorder
(DSM-V, 2013)
(DSM-V, 2013)
– Play skills
– Speech and language skills
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Pragmatic Language in Young Children
Electronic toys/tablets/media???
■ Traditional toys support language and parent/child
interaction better than electronic toys (Sosa, 2016)
■ American Academy of Pediatrics (AAP) (Pediatrics,
2011):
– Recommends little or no screen time prior to 2
years of age
– Limited screen time after 3 years of age with
parental guidance.
■ Co-engagement and content matter (Brown et al., 2015)
■ Function
■ Means of communication
■ Reciprocity
■ Social use
■ Play
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Function
■ Why is the child communicating?
EVALUATION
■ Three main functions (Bates, 1979; Bruner, 1979;
Wetherby & Prizant, 2002)
■ Behavior regulation
■ Social interaction
■ Joint Attention
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Means of Communication
Reciprocity
■ Gestures
– Conventional gestures
– Distal
– Iconic
– Signing
■ Response to another communicator
■ Range of communicative acts
■ Frequency of communicative acts
■ Repair strategies
■ How is the child communicating?
■ Vocalizations (i.e., babbling)
– McCune & Vihman (2001); Wetherby et al. (2007)
■ Verbalizations (i.e., meaningful speech)
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Social Aspects of Communication
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Play
■ Constructive
■ Representational/Symbolic
– Kennedy et al. (1991)
– Bates et al. (1989)
■ Eye Contact/gaze
■ Body posture/distance
■ Appropriate facial expression or social
responses
■ Social initiations and terminations
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Communicative Temptations (Warren & Yoder,
1998; Wetherby & Prizant,1989)
■ Eat a favorite food and do not give any to child
■ Wind-up toy
■ Blocks with bucket
■ Bubbles
■ Ball rolling
■ Balloon
■ Do something silly
■ Sabotage a routine
■ Pay less attention to child
Description
Example
12 months
Use objects in a partially
appropriate way.
15 months
Puts all items into one container
May put baby in bed and cover
with blank but cover face; May
brush baby’s hair by patting head
with brush
18 months
2 or more action schemes with
different objects
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2 or more action schemes with
same objects
3 or more action schemes
May put all dolls into crib; no
orientation
Pushes truck; feeds baby with
spoon; gives parent drink with cup
Feeds doll with spoon, then self;
pushes car, then tractor
Dial phone, put phone to ear, talks
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CSBS
■ Purposes:
– Early identification of children who have, or are at
risk for developing, a communication impairment
■ Normed referenced assessment
■ Population:
– Children with functional communication between 8 and 24 months
– Infants, toddlers and preschool children
– Ages 8-24 months
– 8-months to 5-6 years if their functional communication is in these
communication stages:
– For establishment of a profile of communication,
social-affective, and symbolic functioning from
which to monitor change over time and to develop
intervention goals
Prelinguistic
Early one-word
Late one-word
Multi-word
H. L. Balog - ICCD 4.7.16 Pediatric Pragmatic Language
Age
24 months
Communication and Symbolic Behavior
Scale (CSBS; Wetherby & Prizant, 2003)
■
■
■
■
■ Suggested play things: dolls and baby items (basic clothing and care, phone),
food and feeding items, animals, cars/trucks/boats.
21 months
■ Shared book reading
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Assessing play (Carpenter, 1987)
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CSBS
The Rossetti Infant-Toddler Language
Scale (Rossetti, 2006)
■ Measures:
– Communicative function
– Communicative means – Gestural
– Communicative means – Vocal
– Communicative means – Verbal
– Reciprocity
– Social-Affective Signaling
– Symbolic Behavior
■ Scoring
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The Rossetti
■
Skills assessed:
– Interaction-attachment
– Pragmatics
– Gesture
– Play
– Language comprehension
– Language expression
Population:
– Ages birth to 3 years
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The Rossetti - Interpretation
■ Begin the assessment 6 months below child’s current age on the InteractionAttachment portion
– Establish basal – must pass all items in that area or drop down
– Continue in each developmental level until fails all items for a
developmental level (ceiling).
■ Prognostic (predictive)
– Statement regarding long-term outcome for
progress and/or treatment
■ Rate (pattern) of change
– Normal/abnormal development
– Abnormal/abnormal development
– Catch-up growth
■ Note behavior in three ways:
– Observed
– Elicited
– Reported
H. L. Balog - ICCD 4.7.16 Pediatric Pragmatic Language
Criterion referenced assessment
■
■ Administration
H. L. Balog - ICCD 4.7.16 Pediatric Pragmatic Language
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■ Prescriptive
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The Rossetti – Severity Guidelines
■ Mild delay
– Ceiling level is 2 ranges below chronological age
(i.e., 6 months below)
■ Moderate delay
– Ceiling level is 6-12 months below chronological age
INTERVENTION
■ Severe delay
– Ceiling level is 15 months below chronological age
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Long term goal: Expand use of socialaffective signals
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Long term goal: Enhance Reciprocity
■ Foster facilitative interaction style
– Short term goal: Clinician/parent will imitate child 5 times during
communicative interactions during which there is positive shared affect.
– Short term goal: Child will smile 3/5 times when clinician/parent smiles
at them.
– Short term goal: Child will establish eye contact 3/5 times when
clinician/parent call his/her name.
■ Establish/increase reciprocal responses
– Short term goal: Child will establish turn-taking interactions with
caregiver 3/5 in treatment with eye-gaze, vocalization or verbalizations.
■ Provide opportunities for social referencing
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■ Increase reciprocity and turn-taking
– Short term goal: Child will participate in turn-taking exchanges(i.e.,
games or conversation) ___% of the time.
– Short term goal: Child will increase the number of turns in an exchanges
to ____ over time.
■ Increase rate of communication
– Short term goal: Child will increase the number of communicative
attempts per minute over time (baseline = 1/minute).
■ Repairs
– Short term goal: Child will be able to report 3/5 sabotaged
communication exchanges.
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Long term goal: Expand Range of
Communicative Function
Long term goal: Expand Range of
Communicative Function
■ Increase joint attention
– Short term goal: Child will attempt to get caregiver’s
attention and/or follow their lead ___% of the time during
treatment.
– Short term goal: Child will give clinician requested items
with ___ % accuracy.
– Short term goal: Child will comment and establish joint
referencing ___/minute in appropriate contexts.
■ Increase behavior regulation
– Short term goal: Child will communicate to regulate behavior (i.e.,
request help, protest, etc.) during ___% of appropriate contexts when
presented with communicative temptations.
■ Increase social interaction
– Short term goal: Child will initiate or communicate to continue social
games (e.g., peek-a-boo) 4/5 times.
– Short term goal: Child will call for comfort when distressed or in need
of help ___% of the time.
– Short term goal: Child will use social greeting 2/3 times as appropriate
in the clinical setting.
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Long term goal: Expand Sophistication of
Communication Means
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Long term goal: Expand Sophistication of
Communication Means
■ Acknowledge and expand child communication
■ Facilitate with Indirect Language Stimulation
Techniques:
– Self & Parallel Talk
– Imitation
– Expansions & Extenstions
– Build ups/Break Downs
– Recasts
■ Encourage appropriate means of communication
■ Provide input that is within the child’s zone of
proximal development
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Long term goal: Expand Sophistication of
Communication Means
■ Short term goals should focus on a developmental progression
– Babbling to single-words to combinations, etc.
– Short term goal: Child will increase his/her consonant
inventory from the current baseline of XXX consonants (i.e.,
[ list ] to the expected 14 consonants for his/her age.
– Short term goal: Child will increase his/her spontaneous
single-words produced spontaneously during treatment
sessions (averaged over consecutive sessions; baseline XX).
H. L. Balog - ICCD 4.7.16 Pediatric Pragmatic Language
■ Increase opportunities for symbolic play
■ Provides an ideal context for language modeling
■ Provides ideal context for natural
communication
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Teaching Parents
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PRAGMATICS IN
OLDER CHILDREN
■ Take turns
■ Imitate
■ Point things out
■ Follow their lead
■ Set up routines
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Long term goal: Expand Symbolic Play
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Assessment
Assessment/Intervention
■ Some normed tools available:
– Children’s Communication Checklist, 2nd Edition (Bishop,
2006)
■ Parent/caregiver rating scale
■ 4-16 years
– Language Use Inventory (O’Neil,2009)
■ 18 months to 47 months
■ In general, you’ll be looking at the following skills:
– Social use of language
– Conversation initiations/closures
– Conversation appropriateness
– Turn-taking
– Conversation management
– Inferencing
– Problem Solving
■ Mostly criterion referenced protocols available
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References
■
Brown, A., Shifrin, D. L., & Hill, D. L. (2015). Beyond ‘turn it off’: How to advise families on media use. Aap News, 36, 54-55.
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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
doi:10.1176/aapi.books.9780890425586.744053
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VIDEO ANALYSES
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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).
Doi:10.1176/appi.books.9780890423349
Bates, E. (1979). The emergence of symbols: Cognition and communication in infancy. New York: Academic Press.
Bates, E., Thal, D., Whitesell, K., Fenson, L., & Oakes, L. (1989). Integrating language and gesture in infancy. Develoment al Pyschology, 25,
1004-1019.
Bishop, D. (2006). Children’s Communication Checklist – Second Edition. London, Englan: Psychological Corportion.
Bruner, J. (1981). The social context of language acquisition. Language and Communication, 1, 155-178.
Carpenter, R. (1987). Play scale. In L. Olswang, C. Stoel-Gammon, T. Coggins, & R. Carpenter (Eds.), Assessing prelinguistic and early
linguistic behaviors in developmentally young children (pp. 44-77). Seattle: University of Washington Press.
Chapman, R. (2000). Children’s language learning: An interactionist perspective. Journal of Child Psychology and Psychiatry, 41, 33-54
Hart, B., & Risley, T. R. (1995). Meaningful differences in the everyday experiences of young American children. Baltimore: Paul H. Brookes.
Kennedy, M. D., Sheridan, M. K., Radlinski, S. H., & Beeghly, M. (1991). Play-language relationships in young children with developmental
delays: Implications for assessment. Journal of Speech and Hearing Research, 34, 112-122.
Lahey, M. (1988). Language disorders and language development. New York: Macmillan.
O”Neil, D. (2009). Language Use Inventory. Ontario, Canada: Knowledge in Development.
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References
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Plumb, A. M., & Wetherby, A. M. (2013). Vocalization development in toddlers with autism spectrum disorder. Journal of Speech, Language,
and Hearing Research, 56, 721-734.
McCune, L., & Vihman, M. M., (2001)., Early phonetic and lexical development: A productivity approach. Journal of Speech, Language, and
Hearing Research, 44, 670-684.
Pediatrics (2011). Policy statement: Media use by children younger than 2 years. American Academy of Pediatrics, 128: 1040-045.
Simmons, E. S., Paul, R., & Vokmar, F., (2014) Assessing pragmatic language in autism spectrum disorder: The Yale in vivo pragmatic protocol.
Journal of Speech, Language, and Hearing Research, 57, 2162,-2173.
Sosa, A.V. (2016). Association of the type of toy used during play with quantity and quality of parent-infant communication. JAMA Pediatrics,
170, 132-137.
Warren, S., & Yoder, D. (1998). Facilitating the transition from preintentional to intentional communication. In A. Wetherby, S. Warren, & J.
Riechle (Eds.), Transitions in Prelinguistic communication (pp. 365-384). Baltimore, MD: Paul H. Brookes/
Wetherby, A., & Prizant, B. (1989). The expression of communicative intent: Assessment guidelines. Seminars on Speech and Language, 10, 7791.
Wetherby, A., & Prizant, B. (2002). Communication and Symbolic Behavior Scale Developmental Profile – First normed edition. Baltimore:
Brookes.
Wilcox, M. J., & Shannon, M. S. (1998). Facilitating the transition from prelinguistic to linguistic communication. In A. M. Wetherby, S. F.
Warren, & J. Reichle (Eds.), Transitions in prelinguistic communication (pp. 385-416). Baltimore: Paul H. Brookes.
Yoder, P., Warren, S., & McCathren, R. (1998). Determining spoken language prognosis in children with developmental disabilities. American
Journal of Speech-Language Pathology, 7, 77-87
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