ABSTRACT
EXAMINATION OF THE ACCURACY OF THE SOCIAL LANGUAGE DEVELOPMENT
TEST FOR IDENTIFICATION OF SOCIAL LANGUAGE IMPAIRMENTS
by Jennifer C. Zeberlein
This study examined the accuracy of the Social Language Development Test—Adolescent and
Elementary versions (SLDT), a norm-referenced test, for identification of social language
impairment in school-age children ages 8-16 years. Participants with social language
impairments secondary to autism spectrum disorder (ASD), Aspergers (AS), or attention deficit
hyperactivity disorder (ADHD) and age and gender matched typically developing children and
adolescents were recruited. Parents completed the Children’s Communicative Checklist-2 (CCC2), a parent report measure, to confirm the presence (clinical group, n = 6) or absence (typical
group, n = 17) of social language impairment. Test sensitivity was calculated to be 33% for both
versions. Test specificity was calculated to be 100% for the Elementary version and 75% for the
Adolescent version. These results suggest that the SLDT has poor sensitivity for identifying
social language impairment and that further examination of the accuracy of this measure is
warranted.
EXAMINATION OF THE ACCURACY OF THE SOCIAL LANGUAGE DEVELOPMENT
TEST FOR IDENTIFICATION OF SOCIAL LANGUAGE IMPAIRMENTS
A Thesis
Submitted to the
Faculty of Miami University
In partial fulfillment of
The requirements for the degree of
Masters of Arts
Department of Speech Pathology and Audiology
by
Jennifer C. Zeberlein
Miami University
Oxford, Ohio
2014
Advisor: ______________________________
Geralyn Timler, Ph.D.
Reader: ______________________________
Dawn Girten, M.A. CCC-SLP
Reader: ______________________________
Lisa Williamson, M.S. CCC-SLP
Table of Contents
I. List of Tables
II. List of Figures
III. Literature Review
A. Social Language Framework
B. Social Language Across Disorders
C. Social Language Assessment
IV. Methods
A. Participants
B. Procedure
C. Materials
i. K-BIT
ii. CELF-5 Screener
iii. SLDT-E
iv. SLDT-A
v. CCC-2
vi. CPRS
vii. SSIS
V. Data Analysis
VI. Results
VII.
Discussion
VIII.
References
IX. Appendices
A. Appendix A
ii iii
iv
1
3
4
8
8
9
9
9
9
11
13
14
14
16
17
20
23
27
List of Tables
Table 1.
Mean differences reported for typical and language disordered sample groups in
SLDT……………………………………………………………………………15
Table 2.
Mean differences reported for typical and children/adolescents with ASD sample
groups in SLDT………………………………………………………………....15
Table 3.
Calculations of sensitivity and specificity………………………………………16
Table 4.
Scores of Child Identified with Social Language Impairment with SLDT-E…..18
Table 5.
Scores of Child Identified with Social Language Impairment with SLDT-A….18
iii List of Figures
Figure 1.
Interactive dot diagram demonstrating cases correctly and incorrectly classified
by SLDT-E Total Standard Score <85. Sens= sensitivity;
Spec=specificity…………………………………………………………………19
Figure 2.
Interactive dot diagram demonstrating cases correctly and incorrectly classified
by SLDT-A Total Standard Score <85. Sens= sensitivity; Spec=specificity……19
iv Acknowledgements
First and foremost, I would like to express my gratitude to my committee chair, Dr.
Geralyn Timler, who introduced me to my thesis topic. In addition, she has supported me
throughout the process of researching and writing. It would have been impossible to complete
this thesis without her assistance and dedication. Furthermore, I wish to express my appreciation
to my committee members and readers, Dawn Girten and Lisa Williamson. Their valuable input
has helped me to shape this thesis.
In addition to my professors, I would like to thank my parents, family, and friends for
their continued support throughout my graduate career. It was through their support that I was
able to pursue my thesis and graduate degree at Miami University.
v Literature Review
Effective social language skills are essential for developing friendships and interacting
with peers and adults. When a child reaches school age and adolescence, friends become key
players in a child’s socialization and influence their development in a way parents, teachers,
siblings and other peers cannot (Bagwell & Schmidt, 2011). Children with various
communication disorders exhibit poor social interaction, and it is only through effective
assessment that speech-language pathologists can determine the child’s specific difficulties and
identify appropriate targets for intervention (Cohen et al., 1998). One method of assessment
used by speech-language pathologists (SLPs) is norm-referenced standardized testing. The
purpose of this study is to examine the accuracy of a newly published norm-referenced test for
identification of social language deficits in school-age children and adolescents. Before the test is
described, a framework for guiding assessment of social language is presented. Next, a brief
literature review of social language deficits in pediatric populations served by SLPs is
summarized. Finally, criterion- and norm-referenced assessments of social language are
presented.
Social Language Framework
Coggins, Olswang, Carmichael Olson, and Timler (2003) proposed a framework of
social communication competence (SCC) that incorporates three underlying and interacting
processes: language, social cognition, and higher order executive functions. Each process
determines children’s social communicative behavior, or the observable words and actions that
the child executes during social interactions. The communicative behaviors, in turn, reflect a
child’s social communicative competence.
Language skills allow one to share experiences, regulate the environment, and make
sense of the world (Dodd, 2010). In older children, language is the primary way to establish and
maintain social relationships (Coggins, Timler, & Olswang, 2007). Pragmatic language is one’s
ability to use language in specific context for a specific purpose and is essential for language
competency (Adams, 2002). Through this domain, one knows how to initiate, maintain, and
terminate conversations appropriately with listeners. Pragmatic language is contextually and
culturally bound and shaped through personal experiences and familial beliefs, which makes a
developmental approach to assessment difficult. (Young, 2005).
1 Social cognition is the ability to take the listener’s perspective. It is the understanding of
why people respond or act in a particular way and what they are likely to do next (Dodd, 2010;
Coggins et al., 2007). Social cognition requires joint attention, Theory of Mind, and the ability to
recognize emotions and the intentions of others. This component is crucial for conceptualizing
and maintaining healthy social relationships.
Higher order executive functions are foundational for managing the complexity of social
interactions. These functions are defined as, “the ability to be mentally and behaviorally flexible
to changing situations and coherence and smoothness in one’s responses” (Moran & Gardner,
2007, p. 22 as cited in Dodd, 2010). The goals of executive functions include planning and
executing decisions. One must be able to efficiently problem solve in social situations, which
requires language and cognitive processes such as attention, inhibition, initiation, and working
memory (Dodd, 2010).
Pragmatic language, social cognition, and higher order executive functioning work in
synchrony to achieve social language competence. Due to the complexity of the interaction of
these three processes, it is suggested that professionals, such as speech language pathologists and
psychologists, collaborate to determine the underlying causes of a student’s shortcomings in
social language through a language and cognitive perspective (Dodd, 2010).
Social language incompetence occurs when there is a breakdown in one or more of the
three processes. Pragmatic language impairment arises when there is a discrepancy between the
language and context. For example, a child may have difficulty changing, maintaining, and
terminating conversations appropriately. A child with pragmatic language difficulties may find it
hard to talk about topics he or she is uninterested in. Social cognitive deficits arise when there is
an inability to recognize emotions and exhibit social problem solving (Adams, 2002; Cohen et
al., 1998; Dodd, 2010). A child who is unable to recognize another person’s nonverbal language
and hypothesize why one displays this language may have a deficit in social cognition. It is
difficult, if not impossible, to tease out the differences between a pragmatic language and social
cognitive impairment, as the two are often intertwined. Therefore, the two processes tend to be
approached together in assessment. Pragmatic language and social cognition, together, make up
what will be henceforth referred to as social language.
2 Social Language Disorders in Specific Populations
Disorders in social language are secondary features of various developmental and
neurological disorders (Prutting & Kirchner, 1987). Disorders known for this secondary feature
include: autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD),
conduct disorder with co-occurring language impairment, specific language impairment, and
fetal alcohol spectrum disorder (Volden & Phillips, 2010; Reichow et al., 2008; Cohen et al.,
1998; Kim & Kaiser, 2000; Fujiki, Brinton, & Todd, 1996).
Social language disorders are a defining linguistic feature of ASD regardless of where
children fall on the spectrum (Young et al., 2005). Individuals with High Functioning Autism
(HFA) and Aspergers (AS) often display grossly intact semantic and syntactic structures but
have deficits in social language including: initiating and maintaining conversations, focusing on
irrelevant details, understanding metaphorical language, and responding to other’s initiations
(Volden & Phillips, 2010). Not surprisingly, these individuals tend to perform in the normal to
superior range on standardized assessments of language, making it difficult to establish the need
for speech/language services (Reichow et al., 2008). Yet, in real world settings, these individuals
have challenges with various aspects of social language. Without the ability to use social
language effectively, individuals with autism spectrum disorders (ASD) may be limited in their
participation in mainstream academic settings and the community.
Similar, yet less profound, social language deficits have been noted in children with
ADHD. Common social language behaviors observed include: difficulty with conversational turn
taking, excessive talking, interrupting others, and difficulty with cohesion (Kim & Kaiser, 2000;
Geurts & Embrechts, 2008). Although children with ADHD exhibit deficits in social language, it
has been suggested that children may have fewer social language knowledge deficits. In other
words, children with ADHD know how to respond to social situations but fail to apply this
knowledge in everyday interactions (Kim & Kaiser, 2000).
Researchers have uncovered a correlation among conduct disorders with language
impairment and reduced social cognitive processing (Cohen et al., 1998). Children with a
conduct disorder demonstrate deficits in aspects of social problem solving, such as the ability to
define the problem, identify feelings, determine a strategy, and evaluate outcomes based on
hypothetical social situations (Cohen et al., 1998). In turn, these students may be identified as
3 ‘insolent’ and ‘uncooperative’ in the classroom settings, thus limiting classroom participation
(Gilmour, Hill, Place, & Skuse, 2004)
Specific language impairment (SLI) refers to the presence of a language impairment that
cannot be explained by neurological, genetic, and environmental factors. Children with SLI in
the social language domain struggle with forming peer relationships, interact less frequently with
peers in a classroom, and are less preferred playmates than their typical peers (Marton et al.,
2004; Fujiki, Brinton, & Todd, 1996). As a result, children with SLI report: not having enough
friends, being lonely, and never being chosen as a leader in a group situation (Marton et al.,
2004). Moreover, children with SLI demonstrate increased problem behaviors, fewer positive
peer models, and higher rejection rates in social interaction compared with typical peers (Fujiki
et al., 1996).
Finally, social language appears to be a key deficit in children with documented prenatal
alcohol exposure who receive one of the diagnoses under the umbrella term of fetal alcohol
spectrum disorder (FASD). Children with FASD tend to use ambiguous references, leading to
incomplete ties between events, characters, and settings within narratives revealing difficulties
telling listeners what they need to know (Coggins et al., 2007). Caregivers report that children
with FASD do not know how to act in social situations (Coggins et al., 2007). Ultimately, these
findings suggest that these children may have difficulties establishing and maintaining
relationships with their peers.
In summary, many populations of children served by SLPs exhibit social language
deficits. One challenge for the SLP is that some children score within normal limits on
previously published standardized measures, even when parents and teachers have significant
concerns about social language skills in real world settings. Therefore, new standardized tests of
social language are attempting to develop items that accurately document the impairments
observed in natural communication environments.
Social Language Assessment
The purpose of social language assessment is to identify the “underlying reasons for
communication failure in children’s interactions” (Adams, 2002, p. 974). The assessment should
answer the question: has the child internalized social language rules during communication
(Abdelal, 2009)? Speech language pathologists rely on descriptive developmental measures (e.g.,
checklists, observations, narratives, etc.) and norm-referenced tests to identify children with
4 social language impairment (Adams, 2002; Young et al., 2005). The current study focuses on
norm-referenced measures including parent report measures and tests administered to the
child/adolescent.
One recently developed parent report measure is the Children’s Communication
Checklist-2 (CCC-2: Bishop, 2006). The CCC-2 is perhaps the most widely used, normreferenced parent report measure of social language abilities (Norbury, 2013). The checklist
consists of a 70 items divided into 10 scales with 7 items in each scale. Five of the items in each
scale target communication deficits and two items target communicative strengths. A parent or
caregiver rates the frequency of occurrence from 0 (less than once a week or never) to 3 (several
times a day). The scales include: Speech, Syntax, Semantics, Coherence, Initiation, Scripted
Language, Nonverbal Communication, Social Relations, and Interests. The CCC-2 has been
shown to be a valid measure to differentiate children with high functioning autism, ADHD, and
SLI (Geurts et al., 2004; Geurts & Embrechts, 2008). These measures provide a detailed profile
of the child’s strengths and weaknesses from the perspective of parent/caregiver.
Social language abilities are notoriously hard to identify with standardized measures. The
structure and rigidity of a standardized test makes it difficult to capture social language
breakdowns that occur in authentic environments (Norbury, 2013). Adams (2002) points out that
there is no satisfactory single test of social language, nor one that covers all aspects that should
be assessed in children with suspected deficits. However, standardized measures of social
language offer the ability to compare an individual’s performance to a wider population of
typical and age-matched peers. Although few standardized tests of social language exist, there
has been emerging evidence that these tests are sensitive measures of differential diagnoses of
social language disorders (see Table 1).
Young et al. (2005) compared the scores of the Test of Pragmatic Language (TOPL:
Phelps-Terasaki, & Phelps-Gunn, 1992) with a Strong Narrative Assessments Procedure (SNAP:
Strong, 1998) in children with and without the diagnosis of Autism Spectrum Disorder (ASD).
The SNAP is a criterion-referenced measure that examines a child’s formation of a narrative
through number of communication units, mean sentence length, vocabulary count, conjunctive
and cohesive devices, and story grammar (Young et al., 2005). Results indicated that children
with ASD performed significantly worse than age-matched controls on the TOPL. Additionally,
the TOPL differentiated children with ASD from the control group, while the SNAP did not. The
5 researchers concluded that the qualitative data ascertained from standardized assessments, such
as the TOPL, would be a valuable component for a battery of language tests (Young et al., 2005).
Volden & Phillips’s (2010) study revealed different results than Young et al. (2005). The study
compared the TOPL to the CCC-2 to determine the relative accuracy in identifying social
language impairments in sixteen individuals with ASD. The TOPL displayed a sensitivity of .56,
indicating that only 56% of the participants with ASD were identified as having social language
impairments, while the CCC-2 displayed a sensitivity of .81, or correct identification of 81% of
the participants (Volden & Phillips, 2010). In this study, the CCC-2 was substantially more
accurate at identifying social language impairments than the TOPL. It serves as a reminder that
no one test should be used in the diagnosis of social language impairments.
A follow up study completed by Reichow et al. (2008) supported these findings through
the comparison of the Inference, Nonliteral Language, and Pragmatic Judgment subtests of the
Comprehensive Assessment of Spoken Language (CASL: Carrow-Woolfolk, 1999) to the
communication and social skills scales on the Vineland Adaptive Behavior Scales (Vineland;
Sparrow, Bella, & Cicchetti, 1984). Significant correlations were found between the Pragmatic
Judgment subtest of the CASL with the Communication domain of the Vineland and the
Inferences subtest of the CASL with the Socialization domain. The researchers suggest the
subtests may serve to represent a valid measure of social language abilities in students with ASD
(Reichow et al., 2008).
Overall, standardized social language assessments have been used to assist in the
diagnosis of social language impairment. When used with other criterion-referenced measures,
social language assessments have been found to be reliable measures to discriminate populations
with and without social language impairment The purpose of the current study was to examine
the accuracy of two newly published norm-referenced tests: the Social Language Development
Test- Elementary (SLDT-E, Bowers, Huisingh, & LoGiudice, 2008) and the Social Language
Development Test- Adolescent (SLDT-A, Bowers, Huisingh, & LoGiudice, 2010). The authors
state that these tests were designed “to assess the social language functioning of typically
developing students on various social language tasks” in order to “enhance our understanding of
how typical children understand and use social language skills” (Bowers et al., 2008, p. 9). Both
the SLDT-E and SLDT-A focus on the following skills: reading someone’s expression, inferring
someone’s thoughts based on nonverbal language and situational context, taking someone’s
6 perspective in a conflict situation, and using language to maintain friendship (Bowers et al.,
2008, p. 10).
To the author’s knowledge, there have been no published studies regarding the accuracy
of the SLDT-E and SLDT-A for identification of social language difficulties in school-age
children between the ages of 6;0-18;0 (years; months). The objective of this study is to examine
the accuracy of the Social Language Development Test—Adolescent and Elementary versions
(SLDT), a norm-referenced test, for identification of social language impairment in school-age
children ages 8-16 years.
7 Methods
Participants
IRB approval was obtained prior to recruitment procedures. School-age children and
adolescents, ages 8-16 years were recruited through flyers distributed in local businesses and
schools in the region. Data collection was completed from September 2013 through January
2014. Archival data from participants who had received the same protocol as described below
was also included in this study.
Typically Developing Group. The typical group included 17 children between the ages of
7;8 and 14;11. Thirteen children were between the ages of 7;8 and 11;8 and thus received the
elementary version of the SLDT (see description below). Four children were between the ages of
12;1 and 14;11; these children received the adolescent version of the SLDT.
Clinical Group. Participants in the clinical group included 6 children with the diagnosis
of Aspergers, ASD, and ADHD. Three children were between the ages of 8;0 and 11;1, and 3
children were between the ages of 12;4 and 15;7.
Procedure
Data was collected in one 90-120 minute test session conducted at the Miami University
Speech and Hearing Clinic or at the family’s home. Child assent was obtained prior to the start
of the test administration. All participants were administered the “Matrices” subtest of the
Kaufman Brief Intelligence Test (K-BIT-2: Kaufman & Kaufman, 2004), the Clinical Evaluation
of Language Function- 5th Edition Screening Test (CELF-5: Wiig, Semel, & Secord, 2013), and
the Social Language Development Test- Elementary (SLDT-E: Bowers, Huisingh, & LoGiudice,
2008) or the Social Language Development Test—Adolescent (SLDT-A: Bowers, Huisingh, &
LoGiudice, 2010). Administration of the SLDT was digitally recorded for later scoring.
Participant responses for the remaining tests were written on-line in the test booklets.
In addition to norm-referenced tests, child participants completed two self-report
measures: The Social Skill Improvement System- Student Version (SSIS: Gresham & Elliot,
2008), and The Conversation Participation Rating Scale (CPRS: Timler & Boone, 2011). While
the children were tested, or within one week prior to testing, parents completed a case history,
the Children’s Communication Checklist (CCC-2: Bishop, 2006), and the Social Skills
Improvement System-Parent version (SSIS: Gresham & Elliot, 2008).
8 Measures
K-BIT-2.
The “Matrices” subtest of the K-BIT-2 (Kaufman & Kaufman, 2004) is a brief measure of
nonverbal intelligence of individuals from the ages of 4 through 90 years. This measure was
given to participants to verify that nonverbal intelligence was within an average range. The KBIT takes approximately 10 minutes to administer and an additional 5 minutes for scoring and
interpretation. This subtest is a 46-item nonverbal measure composed of both meaningful (people
and objects) and abstract (design and symbols) visual stimuli. Internal-consistency reliability for
the nonverbal subtest is .86 for ages 4-18, test. Test-retest reliability is reported to be a mean of
.83. The K-BIT-2 is correlated with other cognitive ability tests: the Wechsler Abbreviated Scale
of Intelligence (.8 in older sample, .6 in younger sample) and the Wechsler Intelligence Scale 3rd
edition (.79). Overall, the Matrices subtest of the K-BIT has proven to be a reliable and valid
measure of nonverbal intelligence.
CELF-5 Screening Test.
The CELF-5 screening test was used to classify the participant’s language abilities as at,
or above criterion or below criterion (Semel, Wiig, & Secord, 2013). The test is designed for
individuals between the ages of 5;0 (years; months) and 21;11. Items 1-26 are administered to
students who are ages 5;0 to 8;11 and consist of items from four CELF-5 subtests: Word
Structure, Word Classes, Following Directions, and Recalling Sentences. Items 15-45 are
administered to students ages 9;0-21;11 years and consist of subtest items from: Following
Directions, Recalling Sentences, Sentence Assembly, Semantic Relationships, and Word Classes.
Administration and scoring takes approximately 15 minutes. Test-Retest reliability ranges from
86-94% for three age groups (5;0-6;11, 8;0-9;11, 12;0-16;11). Consistency between the CELF-5
Screening Test and CELF-5 Core Language Score is reported to be .92 for the nonclinical and
language disorder groups (Wiig, Semel, & Secord, 2013, p. 36). Sensitivity for identification of
language impairment is reported to be .90 for the 5:0-8:11 age group and .93 for the 9:0-21:11
age group (Wiig, Semel, & Secord, 2013, p. 37).
SLDT-E.
The SLDT-E (Bowers, Huisingh, & LoGiudice, 2008) is designed to assess social
language and pragmatics for children ages 6;0 through 11;11. It is administered by a speech
9 language pathologist and takes approximately 45 minutes to administer and 30 minutes to score.
An example response book is provided in the assessment kit to assist with scoring.
The SLDT-E is comprised of four subtests: Making Inferences, Interpersonal
Negotiation, Multiple Interpretations, and Supporting Peers. In the Making Inferences subtest
[A], the student is assessed on how well he or she can infer what someone is thinking and
identify the visual clues that led to his or her answer. Responses are scored as 1 or 0. For
example, the child is shown a picture of a crying baby. The student is asked, “Pretend you are
this baby. What are you thinking?” When the student responds the examiner will ask, “What do
you see that tells you what this baby’s thinking?” The student can receive a maximum of 2 points
for each picture for a maximum of 24 points for the entire subtest.
The Interpersonal Negotiation [B] subtest assesses the student’s ability to resolve a
hypothetical conflict with a friend. Responses are scored on a scale of 0 to 3 based on his or her
ability to 1) state the problem from a mutual perspective, 2) use dialogue to propose a mutually
satisfying solution, and 3) explain why that would be a good solution with reference to
maintaining the friendship. For example, the examiner tells a story, “You are watching your
favorite TV show with a friend. Your friend doesn’t like the show and switches the TV channel
to a science show about dinosaurs.”
The Multiple Interpretations subtest [C] assesses the student’s ability to demonstrate
flexibility. The student is shown a picture and asked to give two different, yet reasonable
interpretations. For example, the student is shown a picture of a boy sitting by the side of the
parking lot who appears to be upset. Two correct responses include that the boy is pouting about
something and that he is waiting for someone to pick him up. Scoring, from 0 to 1, is assigned
based on relevancy and quality of the response.
The final subtest, Supporting Peers [D], examines the student’s ability to provide
empathy towards a friend. The student is given hypothetical scenarios where the student must
provide support to friends and peers (e.g. “Your friend got new glasses, but you don’t like them.
What could you say to your friend about her new glasses?”). Scores range from 0 to 4 and are
assigned based on the relevancy and level of support provided.
The SLDT-E yields four subtest standard scores and a total language standard score. No
clinical cut-off scores are provided in the manual. However, one of the authors stated that, “One
standard deviation below the norm is universally considered atypical” (L. Bowers, personal
10 communication, January 28, 2014). Therefore, scores falling below one standard deviation were
considered disordered.
The SLDT-E was standardized on 1,104 participants representative of the 2004 National
Census data for race, gender, age, and educational placement. Inter-rater reliability ranged from
78%-88%, with a mean value of 84%. The test-retest coefficient was .79 and the SEM is 11.26.
Content and construct validity for the SLDT revealed high levels of satisfaction for item
consistency (88%), suggesting the test differentiates among students with autism spectrum
disorders and languages disorders from students with typical language. There was not enough
information provided to calculate sensitivity and specificity for this test, however group mean
differences were calculated for typical, language disordered (LD) groups, and autism spectrum
disorder (ASD) groups. The formula used for this calculation was the clinical group’s mean
score subtracted from the typical group’s mean score and then divided by the larger of the two
group’s standard deviation. As presented in Table 2 below, mean group differences varied by
age.
SLDT-A.
The SLDT-A is designed to assess social language skills for adolescents aged 12;0
through 17;11 (Bowers, Huisingh, & LoGiudice, 2010). The assessment is administered by a
speech language pathologist and takes approximately 45 minutes to administer and an additional
30 minutes to score. An example response book is provided in the assessment kit.
The SLDT-A consists of 5 subtests: Making Inferences, Interpreting Social Language,
Problem Solving, Social Interaction, and Interpreting Ironic Statements. Scoring is based on the
quality and relevancy of a student’s responses. Making Inferences [A] is similar to the SLDT-E.
The student is assigned a score of 1 or 0 based on the student’s ability to provide a direct quote
relevant to the situation plus a specific, clue from the picture (e.g. “Pretend you are this man.
What are you thinking? What do you see that tells you what he’s thinking?”) (Bowers, Huisingh,
& LoGiudice, 2010).
The Interpreting Social Language subtest [B] examines the student’s metalinguistic
abilities and interpretation of idioms. The responses are scored with 1 or 0 based on the student’s
ability to demonstrate action or provide a response plus provide an appropriate reason. In this
subtest, the student is asked to show a posture that sends a message and justify why one would
use that posture.
11 The Problem Solving subtest [C] assesses how well the student proposes and justifies a
logical solution to the given problem. The questions present a scenario such as, “You and your
best friend were always together until recently. Now your friend is dating someone and doesn’t
have time for you. The problem is you miss hanging out with your friend” (Bowers, Huisingh, &
LoGiudice, 2010). Responses are assigned a score of either 1 or 0 based on the student’s ability
to state an appropriate solution and provide justification.
In the Social Interaction subtest [D], the student assumes the perspective of a main
character in a situation with a peer. The student is presented with a scenario such as, “Emma has
a disability that makes it hard to talk well…what do you say to her?” (Bowers, Huisingh, &
LoGiudice, 2010). Responses are scored either 1 or 0. To receive the full score, the student must
provide appropriate and supportive responses.
The final subtest, The Interpreting Ironic Statements [E], is presented on a CD. The
student listens to a vignette and uses clues from the story to identify and explain sarcasm and
irony, understand common idioms, judge speaker’s attitude, and reject the literal meaning of the
statement. Responses are scored 1 or 0 based on the student’s ability to provide an appropriate
response.
The SLDT-A yields five subtest standard scores and a total language standard score. No
clinical cut-off scores were provided in the manual. However, as stated previously, one standard
deviation below the mean (i.e., 85 or lower) was used at the clinical cut-off score in this study
(L. Bowers, personal communication, January 28, 2014).
The SLDT-A was standardized on 500 participants whose demographic characteristics
reflect national school demographics from the latest National Census data. Raw scores and
chronological ages were used to determine standard scores and percentile ranks. The test-retest
coefficient was .82 and the SEM is 4.66 for the total test. Inter-rater reliability was 85%. Given
the uniqueness, clinical population, and scoring criteria, the authors consider the reliability
“highly satisfactory” (Bowers, Huisingh, & LoGiudice, 2010, p. 40). Measurements of validity
were obtained through use of construct and contrasted group validity. Content validity was
considered satisfactory given that the extent of social language development skills assessed as
are developmentally appropriate (Bowers, Huisingh, & LoGiudice, 2010, p. 40). Empirical
validity suggested the test significantly discriminates between the sample and participants with
language disorders and autism spectrum disorders (Bowers, Huisingh, & LoGiudice, 2010, p.
12 42). There was not enough information provided to calculate sensitivity and specificity for this
test, however group mean differences were calculated for typical and language disordered (LD)
groups and autism spectrum disorder (ASD) groups. Mean group differences varied by age and
low and high differences are reported in the Table 3. CCC-2.
The CCC-2 is a norm-referenced parent rating scale for children ages 4;0-16;11 (Bishop,
2006). The CCC-2 takes parents 15 minutes to complete and an additional 15 minutes for scoring
and interpretation. The checklist consists of a 70 items and is divided into 10 scales with 7 items
in each scale. Five of the items in each scale target communication deficits and two items target
communicative strengths. A parent or caregiver rates the frequency of occurrence from 0 (less
than once a week or never) to 3 (several times a day). The scales include: A) Speech (“leaves off
beginning or endings of words”), B) Syntax (“leaves out ‘is’”), C) Semantics (“forgets words he
or she knows”), D) Coherence (“confuses the sequence of events when trying to tell a story”, E)
Initiation (“it is difficult to stop him or her from talking”), F) Scripted Language (“provides overprecise information in his or her talk”), G) Context (“misses the point of jokes and puns”), H)
Nonverbal Communication (“does not look at the person he or she is talking to”), I) Social
Relations (“appears anxious in the company of other children”), and J) Interests (“shows interest
in things or activities that most people would find unusual”).
The CCC-2 yields one composite score, the General Communication Composite (GCC)
and one index score, the Social Interaction Difference Index (SIDI). The GCC is a norm
referenced standard score (M = 100, SD = 15) reflecting overall communication skills; this score
is used to identify clinically significant communication problems and is calculated by summing
scales A through H. The SIDI is a difference index, reflecting the summed difference between
structural language scales (A, B, C, D) and pragmatic language scales (E, H, I, J). SIDI scores
ranging from -10 to 10 are considered typical; scores within this range were obtained by 90% of
the CCC-2 normative sample. Scores ≥ 11 suggest syntactic/semantic skills are deficient and
relatively poorer than pragmatic skills, whereas scores ≤ -11 suggest pragmatic language skills
are deficient and relatively poorer than syntactic/semantic skills; this profile is associated with
autism spectrum disorders (Bishop, 2006).
The US edition of the CCC-2 was standardized on 950 American children. Internal
consistency reliability ranged from .94-.96 across age groups. Validity was assessed by
13 calculating classification rates for a variety of clinically matched groups based on GCC. 89% of
those with ASD were identified as such based on GCC falling 1 SD below the mean.
The CCC-2 examiner’s manual, reports that a GCC score of 85 or lower is associated
with 70% sensitivity (i.e., 70% of children with SLI were identified) and 85% specificity (i.e.,
85% of children who did not have SLI were accurately identified as not having a language
disorder).
CPRS.
The Conversation Participation Rating Scale (CPRS: Timler & Boone, 2011) is a selfreport measure for children and adolescents, ages 8 to 16 years, to assess their perceptions of
participation with peers in the school setting. The current version of the CPRS is comprised of
101 items. The 101 items are organized across two subsets. The first subset of 53 items is titled
“What I say and do with other students at my school,” which includes ratings of the child’s own
behaviors with peers (e.g., “I do not talk about the same topic over and over. I talk about
different topics, (CPRS item #11). The second subset of 48 items is titled “What other students at
school say and do with me,” and elicits ratings about the child’s perceptions of peers’ behaviors
with him/her (e.g., “Students do not talk about the same topic over and over with me. They talk
about different topics, (CPRS item #2-11). Each of the 101 items are rated on a four point scale
of: never/almost never, sometimes, often, and almost always/always.
SSIS.
The Social Skills scale of the Social Skills Improvement System (SSIS: Gresham &
Elliot, 2008) is used in order to gather information on the participant’s social skills including:
communication, cooperation, assertion, responsibility, empathy, engagement and self-control.
The SSIS can be used for children ages 3-18 years of age. The Student and Parent versions of the
SSIS are collected from each participant, with each version containing 46 questions. The
questions on the Student versions include questions such as “I ask for information when I need
it” (item 1) and “I take turns when I talk with others” (item 10). The participants answer each
question with one of four ratings: N = Not True, L = Little True, A = A Lot True, or V = Very
True. The parent version contains questions about their children, such as “Follows household
rules” (item 2) and “Starts conversations with peers” (item 19). The parents answer each
question with one of four ratings: N = Never, S = Seldom, O = Often, or A = Almost Always.
14 Internal consistency reliability for the Parent Form for participants who are ages 5-12 was
.95 and for ages 13-18 was .96. For the Student Form, internal consistency reliability was .93 for
ages 8-12 and .95 for ages 13-18. Test –retest reliability for the parent form (median subscale
reliability) coefficient was .80. For the student form, the median adjusted reliability coefficient
was .71. This value, being lower than the Parent Form, is suggestive that students are less
consistent when interpreting behavioral statements across occasions. Inter-rater reliability for the
Social Skills scale was .62. The authors suggest that the low reliability of this subscale may be
due to low incidence rate of certain behaviors within the subscale. Correlation coefficients for
scales and subscales are calculated from data from 288 individuals ages 3 to 5, 723 individuals
ages 5 to 12 and 289 individuals ages 13 to 18.
Table 1. Mean Group Differences of Typical and LD
Ages
Mean Group Difference
6;0-6;5
.62
8;0-8;5
2.17
14;0-14;11
1.67
17;0-17;11
.91
Table 2. Mean Group Differences of Typical and ASD
Ages
Mean Group Difference
6;6-6;11
3.45
7;6-7;11
1.22
13;0-13;11
2.01
17;0-17;11
5.42
15 Data Analysis
The accuracy of each standardized test was analyzed through calculation of a sensitivity
and specificity ratio using the MedCalc statistical program (Med Calc Software, 1993). Table 3
provides the formulae used in these analyses. Parent ratings (i.e., the CCC-2 results) were used
as the “gold standard” for identifying children with and without social language impairment. To
examine group differences in parent reported social language skills and the relationship among
these skills and the SLDT scores; an unstandardized Pragmatic Composite (PC) score was
calculated (Leonard, Milich, & Lorch, 2011). The PC was calculated by summation of the 6
pragmatic language scales of the CCC-2 (E, F, G, H, I, and J), yielding an unstandardized M=60
and SD=18. Therefore, the clinical cut-off for determining if a child exhibited social language
impairment was a score of 42 or lower. Previous use of the PC yielded a Cronbach’s alpha of .88
(Leonard et al., 2011).
Determination of the presence or absence of social language impairment from the SLDTE and SLDT-A utilized recommended cut-off scores provided in the manuals for each rating
scale. Scores that fell between one standard deviation of the mean were considered within the
normal range. Scores at or below this range (≤ 85) were considered disordered.
In addition, agreement among the SLDT-E and SLDT-A and the CCC-2 were explored
via bivariate correlations. Correlation coefficients of .10, .30, and .50 were considered to be
small, medium, and large, respectively (Green & Salkind, 2005).
Table 3. Calculations for test sensitivity= a/(a +b) and test specificity=d/(c+d)
a) Children with parent reported social
c) Children without parent reported social
language difficulties (i.e., CCC-2 PC score ≤
language difficulties identified incorrectly as
42) identified correctly as impaired on the
impaired on the standardized test (i.e.,
standardized test (i.e., performance at or
performance at or below one standard
below one standard deviation on the SLDT)
deviation)
b) Children with parent reported social
d) Children without parent reported social
language difficulties identified incorrectly as
language difficulties (i.e., CCC-2 PC score >
unimpaired (i.e., performance within or above
42) identified correctly as unimpaired (i.e.,
one standard deviation on the SLDT
performance within or above one standard
deviation on the SLDT)
16 Results
Accuracy of the SLDT
As stated, the CCC-2 PC score was used to classify 6 children in the clinical group and
17 children in the typical group. Sensitivity and specificity for the SLDT-E and SLDT-A are
presented in Figures 1 and 2. The SLDT-E identified 33% of the participants who had social
language impairment, as indicated by deficient performance on the CCC-2. Specificity was
calculated to be 100%. For the Adolescent version, sensitivity was calculated to be 33% while
specificity was 75%. The clinical cutoff identified as most accurate by the Medcalc program was
a standard score of 96: 67% sensitive (95% CI [9.4, 99.2]) and 85% specific (95% CI
[54.6,98.1]). However, a score of 96 is not considered disordered and clinicians could not qualify
a child for services based on this score because it falls within the average range. If a score below
85 is used (i.e., one standard deviation below the mean), the SLDT-E and the SLDT-A correctly
identified one child and one adolescent with social language impairment. SLDT scores of the
children with parent-identified social language impairments are reported in Tables 4 and 5.
Relationships Among the SLDT and CCC-2 Scores
The relationship among subtests of the CCC-2 and the SLDT-E and SLDT-A total
language score was explored through bivariate correlations. The Total Language Scores of both
the SLDT-E and SLDT-A were combined for this measure. Strong correlations were found
between the 6 scales that comprise the PC and the total language scores of the SLDT (.647).
Additionally, the strongest correlations were found the Syntax (.852), Context (.746), and
Coherence (.740) scales of the CCC-2. All values were significant at p ≤ .01 level.
17 Table 4. Scores of Child Identified with Social Language Impairment with SLDT-E
CCC-2 PC
CCC-2
SLDT-E
SLDT-E
SLDT-E
SLDT-E
SLDT-E
GCC
[A]
[B]
[C]
[D]
[Total]
Correctly classified (i.e., children with PC and SLDT scores below clinical cut-offs)
17
59
94
75
62
70
70
Incorrectly classified (i.e., children with PC scores below clinical cut-off who scored above 85
on the SLDT-E)
41
87
89
96
69
90
86
17
76
101
100
103
89
97
Table 5. Scores of Child Indentified with Social Language Impairment with SLDT-A
CCC- CCC-2 GCC SLDT-A
SLDT-A
SLDT-A
SLDT-A
SLDT-A
SLDT-A
2 PC
[A]
[B]
[C]
[D]
[E]
[Total]
Correctly classified (i.e., children with PC and SLDT scores below clinical cut-offs)
35
67
68
65
66
80
83
70
Incorrectly classified (i.e., children with PC scores below clinical cut-off who scored above 85 on
the SLDT-A)
30
78
87
101
77
100
94
90
35
77
78
109
72
109
101
91
18 Figure 1. Interactive dot diagram demonstrating cases correctly and incorrectly classified
by SLDT-E Total Standard Score <85. Sens= sensitivity; Spec=specificity
Figure 2: Interactive dot diagram demonstrating cases correctly and incorrectly classified
by SLDT-A Total Standard Score <85. Sens= sensitivity; Spec=specificity
19 Discussion
The objective of this study was to examine the accuracy of the SLDT-E and SLDT-A for
identification of school-age students with social language impairments. The results of this study
revealed the SLDT-E and SLDT-A exhibited poor sensitivity (33%) for the identification of
children with parent reported social language impairments as determined by the CCC-2 PC
score. Both tests, however, exhibited high rates of specificity. The SLDT-E and SLDT-A were
able to identify the group without pragmatic disorder with 75% to 100% accuracy. The results of
this preliminary study suggest that the SLDT-E and the SLDT-A have low sensitivity when
identifying social language impairments. One third of children in the clinical group were
identified with social language impairment.
Bivariate correlations revealed strong relationships among the total language scores of
the SLDT-E and SLDT-A and the Syntax, Context, and Coherence scales of the CCC-2. This
finding suggests that the SLDT items may tap into student’s grammatical knowledge in addition
to student’s social language knowledge. As such, it may be that students’ syntactic abilities play
a role in their performance on the SLDT.
Overall, the SLDT-E and SLDT-A failed to identify two-thirds of the children with social
language impairment. The two children identified by the SLDT received standard scores of 70,
which fall two standard deviations below the mean, indicating a severe impairment. The children
received General Communicative Competence scores of 59 and 67, respectively, which suggest
the children identified also presented with deficits in structural language. The children with
scores within the moderately impaired range, as reported on the CCC-2, were not identified
through the SLDT. Overall, the SLDT-E and SLDT-A, alone, were not proven to be an accurate
measure of a child’s social language abilities.
Clinical and Research Implications
Standardized social language tests have been notoriously inaccurate in identifying
children with social language impairment (Norbury, 2013). Children with social language
impairments, who have high levels of semantic and syntactic language skills, tend to know how
to respond appropriately in social situations but lack the ability to carry over this knowledge in
everyday interactions (Kim & Kaiser, 2000; Landa, 2000, p. 144). Breakdowns in social
language that occur in the child’s natural environment may not be captured in standardized
assessments.
20 The results of this study support the findings of Volden & Phillips (2010) study, which
compared the accuracy of the TOPL and the CCC-2. It was found that TOPL displayed a
sensitivity of 56%, compared to a sensitivity of 81% for the CCC-2. Therefore, the SLDT, and
other standardized measures of social and pragmatic language, should not be used in isolation to
identify the presence or absence of impairment. A score within the typical range may not exclude
the child from having social language impairment.
In order to make a diagnosis of social language impairment, the evaluation should
encompass a variety of assessment measures including: descriptive developmental assessments,
observations, and standardized assessments. It is recommended that observations of the child
with suspected social language impairment be conducted in natural settings, in order to get a
clear picture of a child’s areas of strength and difficulty (Norbury, 2013).
There are benefits to using the SLDT as a part of the assessment battery. The different
subtests in the elementary (Making Inferences, Interpersonal Negotiation, Multiple
Interpretations, Supporting Peers) and adolescent (Making Inferences, Interpreting Social
Language, Problem Solving, Social Interaction, and Interpreting Ironic Statements) versions are
reported as standard scores. Therefore, it is easy to identify areas of strength and difficulty within
different aspects of social language. In addition, the Examiner’s Manual for both tests provided
error patterns and remediation strategies. These could be used with further social language
interventions.
Limitations and Future Research
Several limitations reduce the ability to generalize these results. The clinical group used
in the study was small (n=6). Three children were administered the SLDT-E and three children
were administered the SLDT-A. Data from additional children is needed to verify or disprove the
results of the current study. Further research of these measures should include a larger sample of
age and gender matched typical and clinical populations.
In the current study, the parent report measures (CCC-2) were used as the “gold
standard” for identifying social language impairment. In further research, it would be beneficial
to include a teacher report measure of social language, as children between the ages of 8-16
spend a majority of the day in a school setting.
Overall, the findings suggest that the SLDT-E and SLDT-A have poor sensitivity when it
comes to identifying children with social language impairment. In this study, only children who
21 showed severe impairment in social language were identified by the SLDT. Further assessment
measures should be collected if parents and teacher report pragmatic and social language
concerns even if the even if the child scores within the average range of the SLDT.
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26 Appendix A
Select Norm-Reference Social Language Tests
Name
Comprehensive
Assessment of Spoken
Language: (CASL)
Social Language
Development TestElementary (SLDT-E)
Authors/Date
CarrowWoolfolk
(1999)
Bowers,
Huisingh, &
LoGiudice,
(2008)
Ages
3:021:11
Social Language
Development TestAdolescent (SLDT-A)
Bowers,
Huisingh, &
LoGiudice,
(2010)
12:017:11
Test of Pragmatic
Language (TOPL-2),
PhelpsTerasaki, &
Phleps-Gunn
(2007)
6:018:11
Test of Problem Solving2 Adolescent (TOPS-2)
Bowers,
Barrett,
Huisingh,
Orman,
LoGiudice
(2007)
12:017:11
6:011:11
27 Description
Inference and
Pragmatic Judgment
subtests
Evaluates making
inferences,
interpersonal
negotiation, multiple
interpretations, and
supporting peers
Perspective taking,
social interpretation,
interpreting visual
cues, and social
interaction. Measure
age-appropriate
skills such as
response to sarcasm,
sensitive
information, and
rumors.
Use of pragmatic
language to
effectively in six
subcomponent areas:
physical setting,
audience, topic,
purpose (speech
acts), visual-gestural
cues, and
abstraction.
Includes questions
that focus on a broad
range of critical
thinking skills
including clarifying,
analyzing,
generating solutions,
evaluating, and
affective thinking.
Research
Reichow et al.
(2008)
Kim & Kaiser
(2000); Young
et al. (2005);
Volden &
Phillips (2010)