When words fail us: insights into language processing from developmental and acquired disorders

Interactive virtual reality training to improve socio-emotional functioning in adolescents with developmental language disorders: A feasibility study

Methods to effectively improve socio-emotional functioning by adolescents with developmental language disorders (DLD) are scarce. Current methods to improve socio-emotional functioning in adolescents with other neurobiological disorders seem less suitable, as these methods are highly language based. This study therefore examined the feasibility of the virtual reality (VR) training for socio-emotional skills: 'InterAction'. The aims of the present study were to (1) examine whether interactive VR is a feasible training method for adolescents with DLD; (2) investigate adolescents' appreciation of the VR training; (3) examine whether the virtual reality training facilitates the participants' sense of presence during social practice situations in an interactive digital world; and (4) explore whether adolescents socio-emotional skills improved during the six-session training. A sample of nine adolescents (13-16 years) with DLD reported on their presence in VR contexts and their appreciation toward the VR training. They also completed weekly self-reports on their socio-emotional functioning. Results indicated that 'InterAction' was a feasible method to practice socio-emotional functioning with adolescents with DLD. Adolescents highly appreciated the VR training. In addition, adolescents rated the sense of presence as high in the VR training. The individual trajectories showed that improvements in the trained skills varied both between and within participants. The results were also not uniform between the specific skills trained. The findings suggest that interactive virtual reality training may be a promising tool for improving socio-emotional functioning in adolescents with DLD. Future studies should examine the positive indications of this study in a larger sample.

Far Transfer Effects of Trainings on Executive Functions in Neurodevelopmental Disorders: A Systematic Review and Metanalysis

Executive Functions are a set of interrelated, top-down processes essential for adaptive goal-directed behaviour, frequently impaired across different neurodevelopmental disorders with variable degrees of severity. Many executive-function-training studies in children with neurodevelopmental disorders have focused on near effects, investigating post-treatment improvements on directly trained processes, while enhancements of skills not directly trained, defined as far effects, are less considered, albeit these could be extremely relevant for reducing the negative impact of a disorder's core symptomatology. This systematic review and metanalysis aims to investigate the far effect outcomes after EF training in children with different types of neurodevelopmental disorders. 17 studies met the inclusion criteria for the systematic review, while 15 studies were selected in the metanalysis. An overall statistically significant effect size was found in the majority of far effect outcome measures considered in the studies. In particular, trainings on executive functions determine significant far effects on daily life functioning (0.46, 95% CI: [0.05-0.87]) and clinical symptoms (0.33, 95% CI: [0.15-0.51]). Despite a high variability of the results, intensity, frequency and the laboratory/life contexts dimension seem to be the most influential variables in determining far effects. This systematic review and metanalysis highlights the need to measure far effects of executive function training in neurodevelopmental disorders, selecting treatments not only on directly targeted processes, but also according to far impacts on the functional weakness of the disorder.

Determining the Linguistic Profile of Children With Rare Genetic Disorders

PURPOSE

Language studies on populations with rare genetic disorders are limited. Hence, there is little data on commonly found or expected developmental linguistic traits and cognitive mechanisms that may be impaired. Based on the hypothesis that there is a close connection between language and cognition and the relevance of specific genetic changes in the development of each, our goal was to provide linguistic data on relationships with other executive functioning mechanisms.

METHOD

This study assessed language skills, communicative behaviors, and executive functions in four children, aged 7-9 years, with rare genetic disorders, using standardized protocols and tests.

RESULTS

The findings revealed different levels of language impairment and executive functioning problems in each case. The overall executive function index performance for each of the four cases studied was clinically significantly high, indicating executive dysfunction.

CONCLUSIONS

The cases analyzed illustrate different types of atypical development that affect both language and other cognitive mechanisms and underscore the importance of executive skills and the various ways in which they are involved in diverse levels of language that might be affected to a greater or lesser degree in rare genetic disorders. In conclusion, we found that language dysfunction is a salient feature of the rare genetic disorders included in our study, although this is not necessarily true for all genetic disorders. Along with these conclusive results, we performed a qualitative analysis of the linguistic and cognitive components that enable functional communication in order to allow optimal interpretation of the data we have collected, laying the foundations for a more effective therapeutic approach.

From terrible twos to sassy sixes: The development of vocabulary and executive functioning across early childhood

Across the early childhood period of development, young children exhibit considerable growth in their executive functioning (EF) and vocabulary abilities. Understanding the developmental trajectory of these seemingly interrelated processes is important as both early vocabulary and EF have been shown to predict critical academic and socio-emotional outcomes later in childhood. Although previous research suggests that EF and vocabulary are correlated in early childhood, much of the existing longitudinal research has focused on unidirectional relations among preschool child samples. The current large-scale study, therefore, sought to examine whether children's vocabulary and EF abilities are bidirectionally related over time across four measurement waves in early childhood (i.e., at ages 2, 3, 4, and 6). At each timepoint, children's vocabulary skills were positively correlated with their concurrent EF abilities. After controlling for child sex and maternal education status, the best-fitting, cross-lagged panel model was a unidirectional model whereby children's early vocabulary scores predicted their later EF performance at each timepoint. Although age 2 EF significantly predicted age 3 vocabulary size, this association was no longer significant after accounting for maternal education status. Our results illustrate that vocabulary size plays an important role in predicting children's later EF performance across various timepoints in early childhood, even after controlling for children's initial EF scores. These findings have important implications for intervention research as fostering early vocabulary acquisition may serve as a possible avenue for improving EF outcomes in young children. RESEARCH HIGHLIGHTS: Children's vocabulary size is positively correlated with their concurrent executive functioning skill at ages 2, 3, 4, and 6 Young children's early vocabulary scores predict their later EF performance across measurement waves, even after controlling for initial EF skill There is stability in children's relative vocabulary size and executive functioning performance over time in early childhood.

Nonverbal Executive Functioning in Relation to Vocabulary and Morphosyntax in Preschool Children With and Without Developmental Language Disorder

PURPOSE

Developmental language disorder (DLD) is characterized by persistent and unexplained difficulties in language development. Accumulating evidence shows that children with DLD also present with deficits in other cognitive domains, such as executive functioning (EF). There is an ongoing debate on whether exclusively verbal EF abilities are impaired in children with DLD or whether nonverbal EF is also impaired, and whether these EF impairments are related to their language difficulties. The aims of this study were to (a) compare nonverbal performance of preschoolers with DLD and typically developing (TD) peers, (b) examine how nonverbal EF and language abilities are related, and (c) investigate whether a diagnosis of DLD moderates the relationship between EF and language abilities.

METHOD

A total of 143 children (nDLD = 65, nTD = 78) participated. All children were between 3 and 6.5 years old and were monolingual Dutch. We assessed nonverbal EF with a visual selective attention task, a visuospatial short-term and working memory task, and a task gauging broad EF abilities. Vocabulary and morphosyntax were each measured with two standardized language tests. We created latent variables for EF, vocabulary, and morphosyntax.

RESULTS

Analyses showed that children with DLD were outperformed by their TD peers on all nonverbal EF tasks. Nonverbal EF abilities were related to morphosyntactic abilities in both groups, whereas a relationship between vocabulary and EF skills was found in the TD group only. These relationships were not significantly moderated by a diagnosis of DLD.

CONCLUSIONS

We found evidence for nonverbal EF impairments in preschool children with DLD. Moreover, nonverbal EF and morphosyntactic abilities were significantly related in these children. These findings may have implications for intervention and support the improvement of prognostic accuracy.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24121287.

How executive functioning, sentence processing, and vocabulary are related at 3 years of age

There is a wealth of evidence demonstrating that executive function (EF) abilities are positively associated with language development during the preschool years, such that children with good executive functions also have larger vocabularies. However, why this is the case remains to be discovered. In this study, we focused on the hypothesis that sentence processing abilities mediate the association between EF skills and receptive vocabulary knowledge, in that the speed of language acquisition is at least partially dependent on a child's processing ability, which is itself dependent on executive control. We tested this hypothesis in longitudinal data from a cohort of 3- and 4-year-old children at three age points (37, 43, and 49 months). We found evidence, consistent with previous research, for a significant association between three EF skills (cognitive flexibility, working memory [as measured by the Backward Digit Span], and inhibition) and receptive vocabulary knowledge across this age range. However, only one of the tested sentence processing abilities (the ability to maintain multiple possible referents in mind) significantly mediated this relationship and only for one of the tested EFs (inhibition). The results suggest that children who are better able to inhibit incorrect responses are also better able to maintain multiple possible referents in mind while a sentence unfolds, a sophisticated sentence processing ability that may facilitate vocabulary learning from complex input.

Executive Functions and Language Skills in Preschool Children: The Unique Contribution of Verbal Working Memory and Cognitive Flexibility

The development of language skills requires a range of linguistic abilities and cognitive processes, such as executive functions (EFs, i.e., a set of skills involved in goal-directed activities which are crucial for regulating thoughts and actions). Despite progress in understanding the link between language and EFs, the need for more research on the extent and directionality of this link is undeniable. This study examined whether specific components of EFs account for a significant amount of variance in language abilities above and beyond gender, age, and nonverbal intelligence. The sample comprised 79 typically developing children attending the last year of preschool (Mage = 64.5 months, SD = 3.47). EFs were assessed through tasks that explored three predictor variables: inhibitory control, working memory, and cognitive flexibility. The language outcomes included receptive and expressive language. After controlling for age, gender, and nonverbal intelligence, findings showed that working memory and cognitive flexibility, respectively, explained an additional 16% and 19% of the variance. Inhibition skills did not increase the amount of explained variance in language outcomes. These results highlight the potential added importance of assessing working memory and cognitive flexibility in the prediction of language skills in preschool children.

Cognitive predictors of language abilities in primary school children: A cascaded developmental view

This study investigated the longitudinal relationship between children's domain-general cognitive constraints underlying phonological and sentence processing development in a big sample of typically developing children. 104 children were tested on non-linguistic processing speed, phonological skills (phonological short term memory, phonological knowledge, phonological working memory), and sentence processing abilities (sentence repetition and receptive grammar) in 1^st grade (aged 6 to 6.5) and one year later. A cross-lagged structural equation model showed that non-linguistic processing speed was a concurrent predictor of phonological skills, and that phonology had a powerful effect on the child's sentence processing abilities concurrently and longitudinally, providing clear evidence for the role of domain-general processes in the developmental pathway of language. These findings support a cascaded cognitive view of language development and pose important challenges for evaluation and intervention strategies in childhood.

Executive functioning and spoken language skills in young children with hearing aids and cochlear implants: Longitudinal findings

Deaf or hard-of-hearing (DHH) children who use auditory-oral communication display considerable variability in spoken language and executive functioning outcomes. Furthermore, language and executive functioning skills are strongly associated with each other in DHH children, which may be relevant for explaining this variability in outcomes. However, longitudinal investigations of language and executive functioning during the important preschool period of development in DHH children are rare. This study examined the predictive, reciprocal associations between executive functioning and spoken language over a 1-year period in samples of 53 DHH and 59 typically hearing (TH) children between ages 3-8 years at baseline. Participants were assessed on measures of receptive spoken language (vocabulary, sentence comprehension, and following spoken directions) and caregiver-completed executive functioning child behavior checklists during two in-person home visits separated by 1 year. In the sample of DHH children, better executive functioning at baseline (Time 1) was associated with better performance on the higher-order language measures (sentence comprehension and following spoken directions) 1 year later (Time 2). In contrast, none of the Time 1 language measures were associated with better executive functioning in Time 2 in the DHH sample. TH children showed no significant language-executive functioning correlations over the 1-year study period. In regression analyses controlling for Time 1 language scores, Time 1 executive functioning predicted Time 2 language outcomes in the combined DHH and TH samples, and for vocabulary, that association was stronger in the DHH than in the TH sample. In contrast, after controlling for Time 1 executive functioning, none of the regression analyses predicting Time 2 executive functioning from Time 1 language were statistically significant. These results are the first findings to demonstrate that everyday parent-rated executive functioning behaviors predict basic (vocabulary) and higher-order (comprehension, following directions) spoken language development 1 year later in young (3-8 year old) DHH children, even after accounting for initial baseline language skills.

PROTOCOL: School-based language, math, and reading interventions for executive functions in children and adolescents: A systematic review

This is the protocol for a Campbell systematic review. Our primary objective for this systematic review is to examine if preschool and school-based interventions aimed at improving language, literacy, and/or mathematical skills increase children's and adolescents' executive functions. As a secondary objective, we will examine how the effects of language, literacy, and mathematics interventions on executive functions are moderated by the subject of the intervention, child age or grade, the type of EF measured, and the at-risk status of participants. We will also explore how the effects are moderated by other study characteristics, and estimate the effects of the included interventions on language, literacy, and mathematical skills.

Vocabulary and Executive Functioning: A Scoping Review of the Unidirectional and Bidirectional Associations across Early Childhood

Early childhood marks a time where word learning is accompanied by rapid growth in the cognitive processes that underlie self-modulated and goal-directed behavior (i.e., executive functions). Although there is empirical evidence to support the association between executive functioning and vocabulary in childhood, inconsistent findings have been reported regarding the extent to which early executive functioning abilities predict later vocabulary outcomes and vice versa. To clarify the nature of the longitudinal relation between these two processes and to examine what, if any, claims can be made about their interdependence, a critical review of the literature was conducted. Also addressed are the conceptual and/or methodological differences that exist across studies conducted on this topic that may be contributing to some of the discrepancies reported in the longitudinal literature. Finally, this review provides practical and empirically informed future directions to serve as a resource for early childhood researchers advancing this area of study.

The Directionality of the Relationship Between Executive Functions and Language Skills: A Literature Review

It has been demonstrated that executive functions play a significant role in different aspects of the development of children. Development of language is also one of the most important accomplishments of the preschool years, and it has been linked to many outcomes in life. Despite substantial research demonstrating the association between executive function and language development in childhood, only a handful of studies have examined the direction of the developmental pathways between EF skills and language skills, therefore little is known about how these two constructs are connected. In this review paper, we discuss three possible directional relationships between EFs and language development throughout childhood. First, we discuss how EF might affect language functioning. Next, we discuss how language functioning might affect EF. Lastly, we consider other possible relationships between EF and language. Given that children with better EF and language skills are more likely to succeed in educational settings and demonstrate greater social–emotional competencies, investigating the relationship between EF and language in the preschool period provides insight into mechanisms that have not been extensively studied. Furthermore, it could create new opportunities for designing effective and efficient interventions aimed at addressing EF and language deficits during the preschool period which could in turn influence later development.

Dynamic assessment of multilingual children's word learning

BACKGROUND

Teachers and clinicians may struggle to provide early identification to support multilingual children's language development. Dynamic assessments are a promising approach to identify and support children's language development.

AIMS

We developed and studied a novel word learning task that is dynamic and language neutral. It makes use of multilingual children's abilities to apply language transfer, fast mapping and socially embedded language to the learning of new words.

METHODS & PROCEDURES

A total of 26 children attending kindergarten in French participated in this study. Within this group, 13 different home languages were spoken. Children took part in a dynamic assessment task of their word learning that consisted of a test-teach-retest task. Children's scores on this task were compared with their language abilities reported by their parents, amount of language exposure and scores on standardized tests of vocabulary. All tasks were delivered in French.

OUTCOMES & RESULTS

Children had higher accuracy for known words as compared with new words in the task, which may suggest transfer of knowledge from their first language. They also showed increased accuracy in identifying and naming the new words across the three trials, suggesting fast mapping of these new vocabulary items. Finally, the scores on the dynamic task correlated to children's vocabulary scores on the standardized tests, but not parent report of language development, or the amount of exposure to the language of school.

CONCLUSIONS & IMPLICATIONS

This novel dynamic assessment task taps into the process of vocabulary learning, but is less influenced by prior language knowledge. Together, these findings provide insight into early word learning by young multilingual children and proposes a conceptual model for identifying strategies to support second language acquisition.

WHAT THIS PAPER ADDS

What is already known on the subject Many barriers exist with regards to assessing the language abilities of multilingual children when a clinician aims to assess their language abilities in both languages. An alternative approach is to measure children's language processing abilities. What this paper adds to existing knowledge A novel dynamic and multilingual task was developed and implemented in this study. This task builds on children's word learning abilities that include cross-language transfer, fast-mapping, and socially imbedded learning. This multilingual task was found to tap into vocabulary learning but was not influenced by prior language knowledge. What are the potential or actual clinical implications of this work? Applying a task that focuses on language processing abilities is a promising strategy to capture language abilities in multilingual children. In addition, the dynamic nature of this tasks allows a clinician to identify scaffolding strategies that best support children's word learning.

Intervention for oral language comprehension skills in preschoolers with developmental language disorder

BACKGROUND

There is a clear predominance of programmes aimed at improving aspects related to language production in pupils with developmental language disorder (DLD). However, programmes aimed at improving their receptive skills are limited.

AIMS

The main aim was to assess the effectiveness of an intervention programme for oral language comprehension skills in preschoolers with typical development (TD) and pupils with DLD.

METHODS & PROCEDURES

Participants were 99 five-year-old pupils, with and without DLD, divided into four groups: two control groups (TD-C = 25; DLD-C = 25) and two experimental groups (TD-T = 24; DLD-T = 25), from schools on the Spanish island of Tenerife. The study used, as pre- and post-measures, the receptive language subtests of the CELF-4-Spanish: Concepts and Following Directions, Word Classes-Receptive and Sentence Structure, as well as two tasks assessing comprehension of paragraphs and narratives. Due to the strong link between oral comprehension skills and executive functions, working memory and semantic fluency are included in this research. The Backward Digit Span subtest of the Wechsler Intelligence Scale for Children (WISC-IV) and Semantic Fluency subtest of the Controlled Oral Word Association Test (COWAT) were used to assess working memory and semantic fluency, respectively. The intervention programme followed a multitiered system of support (MTSS) model, with 95 sessions lasting 60 min each delivered jointly by teachers and speech and language therapists, and focused on lexical-semantic, morphological, syntactic and narrative skills; inferences; verbal working memory; and semantic fluency.

OUTCOMES & RESULTS

The results showed, as expected, that pupils diagnosed with DLD initially performed worse on oral language comprehension and executive functions than pupils with TD. Further, the DLD-T and TD-T groups showed greater gains following the programme, especially in word classes-receptive, sentence structure, verbal working memory and semantic fluency. Finally, a significant positive correlation was found between the gains obtained by the participants in verbal working memory and semantic fluency, with the gains obtained in the three CELF-4-Spanish subtests.

CONCLUSIONS & IMPLICATIONS

An intervention programme applied at an early age fosters oral language comprehension skills and executive functions in pupils with DLD and TD. The intervention organized at different levels of support, following an MTSS model, showed clear progress of the DLD and TD groups in oral language comprehension and executive functions.

WHAT THIS PAPER ADDS

Pupils with DLD present deficits in linguistic comprehension and executive functions. There are many intervention programs focused on improving language production skills. It is also necessary to consider the skills underlying language problems in pupils with DLD. Oral language, inference, working memory and semantic fluency activities improve comprehension. A collaborative and inclusive intervention of teachers and speech language therapists. Psycholinguistic and neuropsychological skills training should become part of the academic curriculum as early as preschool age. What is already known on the subject Pupils with DLD show problems related to both comprehension and production language. However, there is a clear predominance of programs just aimed at improving aspects related to language production. Clinical implications of this study An intervention program applied at an early age fosters oral language comprehension skills and executive function in pupils with DLD. The intervention organized at different levels of support, following an adaptation of the Response Tier Intervention models, showed clear progress of the DLD in comprehension oral language and executive functions.

Variation in Auditory Experience Affects Language and Executive Function Skills in Children Who Are Hard of Hearing

OBJECTIVE

Children who are hard of hearing (CHH) experience delays in spoken language and executive function, but the mechanisms for these deficits remain unresolved. Differences in auditory experience and language skills have been examined as contributing factors to deficits in executive function, primarily with children who are deaf and children with cochlear implants. The theoretical model of cumulative auditory experience quantifies auditory dosage as how much speech is audible and how often children wear their hearing aids. CHH with higher auditory dosage have better language outcomes than peers with less auditory dosage. However, the effects of auditory experience on executive function have not been studied in CHH. The goal of this study was to examine the influences of auditory experience and language skills on the development of executive function in CHH.

DESIGN

We collected measures of aided speech audibility, hearing aid use, executive function, and receptive vocabulary in 177 CHH and 86 children with typical hearing who were 5- to 10 years old and matched for socioeconomic status and nonverbal intelligence. Auditory dosage was calculated by combining each child's average hours of hearing aid use with their audibility for speech to create a variable that quantifies individual differences in auditory access.

RESULTS

CHH had lower receptive vocabulary and deficits in executive function related to working memory and selective attention compared to peers with typical hearing. CHH with greater auditory dosage had higher receptive vocabulary than CHH with lower auditory dosage. Better receptive vocabulary was associated with better scores on executive function measures related to working memory and attention. Auditory dosage was also directly associated with measures of verbal working memory.

CONCLUSIONS

CHH have deficits in language and some, but not all, areas of executive function related to working memory and attention. Auditory dosage was associated with language abilities and verbal working memory. Language was associated with individual differences in executive function skills related to attention and working memory. These results provide support for systems theories regarding the development of executive function in CHH. Interventions that improve auditory access and language may be effective for improving executive function related to working memory and attention in CHH.

Lexical and Grammatical Errors in Developmentally Language Disordered and Typically Developed Children: The Impact of Age and Discourse Genre

Persistent lexical and grammatical errors in children’s speech are usually recognized as the main evidence of language delay or language disorder. These errors are usually treated as a sign of a deficit in language competence. On the other hand, some studies have revealed the same kinds of grammatical errors in children with developmental language disorder (DLD) and in typically developed (TD) children. Quite often, DLD children use grammatical markers properly, but sometimes they do this erroneously. It has been suggested that the main area of the limitations in DLD children is language performance but not language competence. From the perspective of the resource deficit model, the error rate in DLD children should be influenced by the cognitive demands of utterance and text production. We presume that different genres of discourse demand a different number of cognitive resources and, thus, should differently impact the error rate in children’s speech production. To test our hypothesis, we carried out an error analysis of two corpora of child discourse. The first corpus contained longitudinal data of discourse (personal narratives, fictional stories, chats, and discussions) collected from 12 children at four age points (4 years 3 months., 4 years 8 months., 5 years 3 months., and 5 years 9 months. years). Another corpus contained discourse texts (fictional stories and discussions) collected in the framework of a cross-sectional study from 6-year-old TD and DLD children; the DLD children had language expression but not comprehension difficulties. A comparative analysis between different discourse genres evidenced that the genre of discourse and age of assessment impacted the error distribution in the DLD and TD children. Such variables as the lexical and morphological error rates were impacted the most significantly. The results of the two studies confirmed our hypothesis regarding the probabilistic nature of lexical and grammatical errors in both DLD and TD children and the relationship between a cognitive loading of the genre and the error rate.

The interplay between early social interaction, language and executive function development in deaf and hearing infants

In this article, we review the influence of early social interaction on the development of executive function and language in infants. We first define social interaction, executive function and language and show how they are related in infant development. Studies of children born deaf are used to illustrate this connection because they represent cases where there has been a disruption to early social interaction and the development of intersubjectivity. Unlike other groups, the disturbance to development is known to be largely environmental rather than neuro-biological. This enables us to more accurately tease apart those impacts on EF that are associated with social interaction and language, since the potential confounds of disordered cognitive development are largely controlled for. The review offers a unifying model for how social, cognitive and linguistic development work together in early human development.

Executive Function, Language, and the Toddler's Discovery of Representational Drawing

Working memory capacity and executive functions play important roles in the early development of drawing and language, but we lack models that specify the relationships among these representational systems and cognitive functions in toddlers. To respond to this need, the present study investigated the relations between drawing and language in very young children, and the role of working memory capacity, inhibition, and shifting in the association between these two representational systems. The participants were 80 children, 25–37 months old. The results revealed that in toddlers (a) all the measures of working memory, inhibition, and shifting loaded on a single factor of general executive functioning; (b) language and drawing are two distinct, but substantially correlated, representational systems; and (c) the development of executive function has a strong impact on language development, which in turn influences the development of drawing.

Understanding differing outcomes from semantic and phonological interventions with children with word-finding difficulties: A group and case series study

Developmental Language Disorder occurs in up to 10% of children and many of these children have difficulty retrieving words in their receptive vocabulary. Such word-finding difficulties (WFD) can impact social development and educational outcomes. This research aims to develop the evidence-base for supporting children with WFD and inform the design and analysis of intervention studies. We included 20 children (age 6 to 8) with WFD each of whom participated in two interventions one targeting semantic attributes and the other phonological attributes of target words. The interventions, employing word-webs, were carefully constructed to facilitate direct comparison of outcome which was analysed at both group and case-series level. The study used a robust crossover design with pre-intervention baseline, between-intervention wash-out and post-intervention follow-up testing. We incorporated: matching of item sets on individual performance at baseline, independent randomisation of order of intervention and items to condition, blinding of assessor, evaluation of fidelity and control items. The interventions were clinically feasible, with weekly sessions over six weeks. Intervention improved children's word-finding abilities with statistically significant change only during treatment phases of the study and not over baseline, wash-out or follow-up phases. For the group the semantic intervention resulted in a gain of almost twice as many items as the phonological intervention, a significant difference. However, children differed in their response to intervention. Importantly, case-series analysis revealed outcomes predictable on the basis of children's theoretically driven language profiles. Taking account of individual profiles in determining choice of intervention would enable more children to benefit. The study provides new evidence to inform and refine clinical practice with this population. Future studies should be designed such that results can be analysed at both group and case series levels to extend theoretical understanding and optimise use of appropriate interventions.

Word Form Processing in Primary School Children: A Psycholinguistic Perspective

Purpose From a psycholinguistic perspective, the quality of the stored word form in the phonological input lexicon, as well as its effective retrieval from the phonological output lexicon, is of great importance in lexical processing. This study aimed at gaining a deeper understanding of (a)typical word form processing in primary school children. In particular, age-related development and profiles of word form processing including children's response behavior were investigated. Method A sample of 164 monolingual primary school children (6-9 years of age) was tested in a cross-sectional design using two word form-related tasks (auditory lexical decision and rapid naming) with carefully controlled stimuli in combination with traditional vocabulary tests and a nonword repetition task. Results First, an age-related improvement (better performance and acceleration of reaction times) was found for both word form-related tasks. Second, a cluster analysis revealed five clusters with different profiles of word processing. Beside a cluster with overall results of above average, we found two clusters including children with typical lexical abilities who applied specific strategies to deal with the tasks (speed-accuracy trade-offs). Two other clusters represented weak lexical abilities at different levels of word processing. Conclusions Children's abilities in word form processing develop over time and are characterized by developmental boosts that occur at different times in development. The uncovered profiles document patterns of (a)typical lexical processing. Since difficulties with word form processing are easily overlooked in clinical assessment, lexical decision and rapid naming tasks offer valuable tools for an in-depth evaluation of lexical skills. Supplemental Material https://doi.org/10.23641/asha.12986036.

Associations between stuttering, comorbid conditions and executive function in children: a population-based study

Background

The aim of this study was to investigate the relationship between executive function (EF), stuttering, and comorbidity by examining children who stutter (CWS) and children who do not stutter (CWNS) with and without comorbid conditions. Data from the National Health Interview Survey were used to examine behavioral manifestations of EF, such as inattention and self-regulation, in CWS and CWNS.

Methods

The sample included 2258 CWS (girls = 638, boys = 1620), and 117,725 CWNS (girls = 57,512; boys = 60,213). EF, and the presence of stuttering and comorbid conditions were based on parent report. Descriptive statistics were used to describe the distribution of stuttering and comorbidity across group and sex. Regression analyses were to determine the effects of stuttering and comorbidity on EF, and the relationship between EF and socioemotional competence.

Results

Results point to weaker EF in CWS compared to CWNS. Also, having comorbid conditions was also associated with weaker EF. CWS with comorbidity showed the weakest EF compared to CWNS with and without comorbidity, and CWS without comorbidity. Children with stronger EF showed higher socioemotional competence. A majority (60.32%) of CWS had at least one other comorbid condition in addition to stuttering. Boys who stutter were more likely to have comorbid conditions compared to girls who stutter.

Conclusion

Present findings suggest that comorbidity is a common feature in CWS. Stuttering and comorbid conditions negatively impact EF.

The association between communication impairments and acquired alexithymia in chronic stroke patients

INTRODUCTION

Language dysfunction has recently been suggested to be one route to alexithymia, an impairment in recognizing and communicating one's own emotions. Neuropsychological evidence is needed to investigate the possibility that acquired language problems could underlie acquired alexithymia.

METHOD

This project examined data from a large group of chronic stroke patients (N = 118) to test whether self-reported or behavioral measures of language and communication problems were associated with alexithymia. We also examined the impact of hemisphere of damage on alexithymia.

RESULTS

We found no differences in alexithymia levels for patients with observed language impairments on brief tests of picture naming, comprehension, and reading vs unimpaired patients. However, self-reported communication difficulties were found to be associated with higher scores of alexithymia, even after controlling for depression and anxiety. Patients with left- versus right-hemisphere damage did not differ in their alexithymia scores.

CONCLUSIONS

We found partial support for the language hypothesis of alexithymia. We discuss potential reasons for the discrepant findings between the self-report and objective language measures and suggest that self-report measures may be more sensitive to milder, more pragmatic language impairments, as opposed to the severe structural language impairments measured by the cognitive screening tests.

Developmental transformations in the structure of executive functions

Comparisons of results from studies of executive function (EF) in early childhood to those of EF in middle and late childhood suggest that individual differences in EFs may differentiate from a unitary factor in early childhood to an increasingly multidimensional structure in middle childhood and adolescence. We tested whether associations among EFs strengthened from middle childhood to adolescence using cross-sectional data from a population-based sample of 1019 children aged 7-15 years (M = 10.79 years). Participants completed a comprehensive EF battery consisting of 15 measures tapping working memory, updating, switching, and inhibition domains. Moderated factor analysis, local structural equation modeling, and network modeling were applied to assess age-related differences in the factor structure of EF. Results from all three approaches indicated that working memory and updating maintained uniformly high patterns of covariation across the age range, whereas inhibition became increasingly differentiated from the other three domains beginning around 10 years of age. However, consistent with past research, inhibition tasks were only weakly intercorrelated. Age-related differences in the organization of switching abilities were mixed.

Executive control in language production by children with and without language impairment

BACKGROUND

Accumulating evidence suggests that the updating, inhibiting and shifting abilities underlying executive control are important for spoken language production in adults. However, little is known about this in children.

AIMS

To examine whether children with and without language impairment differ in all or only some of these executive abilities, and whether they show corresponding differences when these abilities are engaged in language production.

METHODS & PROCEDURES

Thirty-three children with specific language impairment (SLI) and 41 typically developing (TD) children (age matched, aged 8-12 years) completed standard executive control tests that measure the updating, inhibiting and shifting abilities. All children were native speakers of Dutch. Moreover, they performed a noun-phrase production task involving picture description within a picture-word interference paradigm. We measured their production accuracy and speed to assess length, distractor and switch effects, which reflect the updating, inhibiting and shifting abilities underlying executive control.

OUTCOMES & RESULTS

Compared with TD children, the children with SLI had lower scores on all executive control tests. Moreover, they were overall slower and made more errors in the noun-phrase production task. Additionally, the magnitude of the distractor and switch effects was larger for the SLI than for the TD group.

CONCLUSIONS & IMPLICATIONS

The results suggest that children with SLI have impaired language production and executive control abilities, and that some of the differences in the executive control abilities between SLI and TD groups were reflected in their language production.

Funcionamiento ejecutivo y desempeño lector en niños con y sin dificultades de lectura: Un estudio de seguimiento ocular

Introducción: Las funciones ejecutivas incluyen habilidades como la memoria de trabajo, el control inhibitorio, la planeación y la flexibilidad cognitiva. Estas habilidades, resultan fundamentales para el desarrollo de procesos cognitivos complejos como el aprendizaje de la lectoescritura, encontrando que aquellos niños con dificultades de lectura tienden a presentar un nivel menor en el rendimiento en tareas de funciones ejecutivas. Objetivo: Caracterizar el rendimiento en funciones ejecutivas y su relación con el nivel de lenguaje y lectura en niños de 8 a 12 años con dificultades de lectura y sus controles por edad y género en relación a los patrones de seguimiento visual. Método: Participantes: 9 niños con dificultades de lectura y 9 controles. Procedimiento: Se evaluó el nivel de lenguaje, funciones ejecutivas y lectura haciendo uso del Eye Tracker Tobii Tx300.  Se analizaron los mapas de calor, glaze plot y las áreas de interés. Resultados y Conclusiones: Los niños con dificultades de lectura presentan un nivel de desempeño menor en tareas de funciones ejecutivas especialmente en el control inhibitorio y la planeación, estando estas asociadas directamente con el nivel de lenguaje y el rendimiento lector. De igual forma, las métricas visuales a partir del uso del Eye Tracker permite corroborar estas fallas en el procesamiento en tiempo real frente a tareas que implican demandas cognitivas de alto nivel.  

Expressive Vocabulary Predicts Nonverbal Executive Function: A 2-year Longitudinal Study of Deaf and Hearing Children

Numerous studies suggest an association between language and executive function (EF), but evidence of a developmental relationship remains inconclusive. Data were collected from 75 deaf/hard-of-hearing (DHH) children and 82 hearing age-matched controls. Children were 6-11 years old at first time of testing and completed a battery of nonverbal EF tasks and a test of expressive vocabulary. These tasks were completed again 2 years later. Both groups improved their scores on all tasks over this period. DHH children performed significantly less well than hearing peers on some EF tasks and the vocabulary test at both time points. Cross-lagged panel models showed that vocabulary at Time 1 predicted change in EF scores for both DHH and hearing children but not the reverse.

An Exploration of the Factor Structure of Executive Functioning in Children

There has been considerable debate and interest in the factor structure of executive functioning (EF). For children and young people, there is evidence of a progression from a single factor to a more differentiated structure, although the precise nature of these factors differs between investigations. The purpose of the current study was to look at this issue again with another sample, and try to understand possible reasons for previous differences between investigations. In addition, we examined the relationship between less central EF tasks, such as fluency and planning, to the more common tasks of updating/executive working memory (EWM), inhibition, and switching/shifting. A final aim was to carry out analyses which are relevant to the debate about whether EF is influenced by language ability, or language ability is influenced by EF. We reasoned that if language ability affects EF, a factor analysis of verbal and non-verbal EF tasks might result in the identification of a factor which predominantly contains verbal tasks and a factor that predominately contains non-verbal tasks. Our investigation involved 128 typically developing participants (mean age 10:4) who were given EF assessments that included verbal and non-verbal versions of each task: EWM; switching; inhibition; fluency; and planning. Exploratory factor analyses on EWM, switching, and inhibition produced a structure consisting of inhibition in one factor and the remaining tasks in another. It was decided to exclude verbal planning from the next analyses of all the ten tasks because of statistical considerations. Analysis of the remaining nine EF tasks produced two factors, one factor containing the two inhibition tasks, and another factor that contained all the other tasks (switching, EWM, fluency, and non-verbal planning). There was little evidence that the verbal or non-verbal elements in these tasks affected the factor structure. Both these issues are considered in the discussion, where there is a general evaluation of findings about the factor structure of EF.

Executive Functions and Prosodic Abilities in Children With High-Functioning Autism

Little is known about the relationship between prosodic abilities and executive function skills. As deficits in executive functions (EFs) and prosodic impairments are characteristics of autism, we examined how EFs are related to prosodic performance in children with high-functioning autism (HFA). Fifteen children with HFA (M = 7.4 years; SD = 1.12), matched to 15 typically developing peers on age, gender, and non-verbal intelligence participated in the study. The Profiling Elements of Prosody in Speech-Communication (PEPS-C) was used to assess prosodic performance. The Children's Color Trails Test (CCTT-1, CCTT-2, and CCTT Interference Index) was used as an indicator of executive control abilities. Our findings suggest no relation between prosodic abilities and visual search and processing speed (assessed by CCTT-1), but a significant link between prosodic skills and divided attention, working memory/sequencing, set-switching, and inhibition (assessed by CCTT-2 and CCTT Interference Index). These findings may be of clinical relevance since difficulties in EFs and prosodic deficits are characteristic of many neurodevelopmental disorders. Future studies are needed to further investigate the nature of the relationship between impaired prosody and executive (dys)function.

Verbal Working Memory as a Longitudinal Mechanism of Vocabulary Problems in Preschoolers with ADHD

Elucidation of early potential risk factors of Attention-Deficit/Hyperactivity Disorder (ADHD) is important to allow for early identification of ADHD and targeted early intervention for children with ADHD. Delayed language skills, particularly poor vocabulary, is an early-developing potential risk factor that is thought to be involved in developmental pathways to ADHD; however, mechanisms explaining the relationship between poor vocabulary skills and ADHD symptoms are unclear and warrant investigation. The present study examines the relationship between poor vocabulary skills and ADHD symptoms by testing cognitive mechanisms, namely verbal working memory (WM), that might account for this link. Participants were 109 young children between the ages of three and six and their primary caregivers. Diagnostic information on ADHD symptoms was available from parents and teachers/daycare providers via standardized rating forms. Vocabulary skills and WM were measured through child performance on laboratory tasks. Mediation analyses found poor verbal working memory significantly partially explained the vocabulary-ADHD association for both parent and teacher-rated ADHD symptoms. Further, effects of verbal WM on the association between poor vocabulary and increased ADHD symptoms largely held at one-year follow-up. Development of early interventions targeting verbal WM may be a promising new direction for early ADHD intervention work.

Articulation Speaks to Executive Function: An Investigation in 4- to 6-Year-Olds

Executive function (EF) and language learning play a prominent role in early childhood development. Empirical research continues to point to a concurrent relation between these two faculties. What has been given little attention, however, is the association between EF and speech articulation abilities in children. This study investigated this relation in children aged 4-6 years. Significant correlations indicated that children with better EF [via parental report of the Behavior Rating Inventory of Executive Function (BRIEF) inventory] exhibited stronger speech sound production abilities in the articulation of the "s" and "sh" sounds. Furthermore, regression analyses revealed that the Global Executive Composite (GEC) of EF as measured by the BRIEF, served as a predictor for speech sound proficiency and that speech sound proficiency served as a predictor for the GEC. Together, these results demonstrate the imbricated nature of EF and speech sound production while bearing theoretical and practical implications. From a theoretical standpoint, the close link between EF and speech articulation may indicate a common ontogenetic pathway. From a practical perspective, the results suggest that children with speech difficulties could be at higher risk for EF deficits.

Nonverbal Executive Function is Mediated by Language: A Study of Deaf and Hearing Children

Studies have suggested that language and executive function (EF) are strongly associated. Indeed, the two are difficult to separate, and it is particularly difficult to determine whether one skill is more dependent on the other. Deafness provides a unique opportunity to disentangle these skills because in this case, language difficulties have a sensory not cognitive basis. In this study, deaf (n = 108) and hearing (n = 125) children (age 8 years) were assessed on language and a wide range of nonverbal EF tasks. Deaf children performed significantly less well on EF tasks, even controlling for nonverbal intelligence and speed of processing. Language mediated EF skill, but the reverse pattern was not evident. Findings suggest that language is key to EF performance rather than vice versa.

Exploring the learnability and usability of a near field communication-based application for semantic enrichment in children with language disorders

Recently, a few software applications (apps) have been developed to enhance vocabulary and conceptual networks to address the needs of children with language impairments (LI), but there is no evidence about their impact and their usability in therapy contexts. Here, we try to fill this gap presenting a system aimed at improving the semantic competence and the structural knowledge of children with LI. The goal of the study is to evaluate learnability, usability, user satisfaction and quality of the interaction between the system and the children. The system consists of a tablet, hosting an app with educational and training purposes, equipped with a Near Field Communication (NFC) reader, used to interact with the user by means of objects. Fourteen preschool children with LI played with the device during one 45-minute speech therapy session. Reactions and feedbacks were recorded and rated. The system proved to be easy to understand and learn, as well as engaging and rewarding. The success of the device probably rests on the integration of smart technology and real, tangible objects. The device can be seen as a valuable aid to support and enhance communication abilities in children with LI as well as typically developing individuals.

Explicit and Implicit Verbal Response Inhibition in Preschool-Age Children Who Stutter

PURPOSE

The purpose of this study was to examine (a) explicit and implicit verbal response inhibition in preschool children who do stutter (CWS) and do not stutter (CWNS) and (b) the relationship between response inhibition and language skills.

METHOD

Participants were 41 CWS and 41 CWNS between the ages of 3;1 and 6;1 (years;months). Explicit verbal response inhibition was measured using a computerized version of the grass-snow task (Carlson & Moses, 2001), and implicit verbal response inhibition was measured using the baa-meow task. Main dependent variables were reaction time and accuracy.

RESULTS

The CWS were significantly less accurate than the CWNS on the implicit task, but not the explicit task. The CWS also exhibited slower reaction times than the CWNS on both tasks. Between-group differences in performance could not be attributed to working memory demands. Overall, children's performance on the inhibition tasks corresponded with parents' perceptions of their children's inhibition skills in daily life.

CONCLUSIONS

CWS are less effective and efficient than CWNS in suppressing a dominant response while executing a conflicting response in the verbal domain.

Past, present, and prospects: Reflections 40 years on from the selective impairment of semantic memory (Warrington, 1975)

We summarize the main findings and conclusions of Warrington's (1975) paper, The Selective Impairment of Semantic memory, a neuropsychological paper that described three cases with degenerative neurological conditions [Warrington, E. K. (1975). The selective impairment of semantic memory. The Quarterly Journal of Experimental Psychology, 27, 635–657]. We consider the developments that have followed from its publication and give a selective overview of the field in 2014. The initial impact of the paper was on neuropsychological investigations of semantic loss followed some 14 years later by the identification of Semantic Dementia (the condition shown by the original cases) as a distinctive form of degenerative disease with unique clinical and pathological characteristics. We discuss the distinction between disorders of semantic storage and refractory semantic access, the evidence for category- and modality-specific impairments of semantics, and the light that has been shed on the structure and organization of semantic memory. Finally we consider the relationship between semantic memory and the skills of reading and writing, phonological processing, and autobiographical memory.

Regularity and beyond: Impaired production and comprehension of inflectional morphology in semantic dementia

Studies on inflectional morphology in semantic dementia (SD) have focused on the contrast between the regular and the irregular English past-tense. These studies aimed to contrast the claims of single- and dual-mechanism theories. However, both theories can account for impaired production of irregular verbs observed in SD. According to the dual-mechanism theory, this impairment is related to word-retrieval difficulties, while according to single-mechanism theory it is the consequence of semantic impairment. However, authors suggest that it is time to envision a broader role for semantic memory in the production of semantically encoded aspects of inflectional morphology. This study reports the performance of 10 French-speaking patients with SD in three tasks of inflectional morphology. Their performances were compared to those of a group of 20 age-, gender- and education-matched adults without cognitive impairment. Results show that SD patients had difficulties producing tense and person inflection in verbs and pseudo-verbs, whether regular or pseudo-regular. In a second task in which participants were directly exposed to regularity manipulations, SD patients tended to choose a more typical or predictable alternative over a correctly inflected verb. Results of the third task show that their difficulties in producing semantically encoded aspects of inflection, such as tense, are related to difficulties to understand the semantic content conveyed by inflectional morphemes. Overall, these results support the claim that semantic impairment can cause morphological deficits that do not only affect irregular verbs, but that also have impacts on the production and comprehension of semantic information conveyed by inflectional morphemes.

The development of executive function and language skills in the early school years

BACKGROUND

The developmental relationships between executive functions (EF) and early language skills are unclear. This study explores the longitudinal relationships between children's early EF and language skills in a sample of children with a wide range of language abilities including children at risk of dyslexia. In addition, we investigated whether these skills independently predict children's attention/behaviour skills.

METHOD

Data are presented from 243 children at four time points. Children were selected for being at risk of reading difficulties either because of a family history of dyslexia (FR; N = 90) or because of concerns regarding their language development (LI; N = 79) or as typically developing controls (TD; N = 74). The children completed tasks to assess their executive function and language skills at ages 4, 5 and 6 years. At 6 (T4) and 7 years (T5) parents and teachers rated the children's attention/behaviour skills.

RESULTS

There was a strong concurrent relationship between language and EF at each assessment. Longitudinal analyses indicated a considerable degree of stability in children's language and EF skills: the influence of language on later EF skills (and vice versa) was weak and not significant in the current sample. Children's EF, but not language, skills at T3 predicted attention/behaviour ratings at T4/T5.

CONCLUSIONS

There is a strong concurrent association between language and EF skills during the preschool and early school years, when children with language impairment show persistent EF deficits. Latent variables measuring language and EF show high longitudinal stability with little evidence of significant or strong reciprocal influences between these constructs. EF, but not language, skills predict later ratings of children's attention and behaviour.

Grammatical Class Effects Across Impaired Child and Adult Populations

The aims of this study are to compare quantitative and qualitative differences for noun/verb retrieval across language-impaired groups, examine naming errors with reference to psycholinguistic models of word processing, and shed light on the nature of the naming deficit as well as determine relevant group commonalities and differences. This includes an attempt to establish whether error types differentiate language-impaired children from adults, to determine effects of psycholinguistic variables on naming accuracies, and to link the results to genetic mechanisms and/or neural circuitry in the brain. A total of 89 (language-)impaired participants took part in this report: 24 adults with acquired aphasia, 20 adults with schizophrenia-spectrum disorder, 31 adults with relapsing-remitting multiple sclerosis, and 14 children with specific language impairment. The results of simultaneous multiple regression analyses for the errors in verb naming compared to the psycholinguistic variables for all language-impaired groups are reported and discussed in relation to models of lexical processing. This discussion will lead to considerations of genetic and/or neurobiological underpinnings: Presence of the noun-verb dissociation in focal and non-focal brain impairment make localization theories redundant, but support for wider neural network involvement.The patterns reported cannot be reduced to any one level of language processing, suggesting multiple interactions at different levels (e.g., receptive vs. expressive language abilities).Semantic-conceptual properties constrain syntactic properties with implications for phonological word form retrieval.Competition needs to be resolved at both conceptual and phonological levels of representation. Moreover, this study may provide a cross-pathological baseline that can be probed further with respect to recent suggestions concerning a reconsideration of open- vs. closed-class items, according to which verbs may actually fall into the latter rather than the standardly received former class.

Executive functioning in preschoolers with specific language impairment

The pathogenesis of Specific Language Impairment (SLI) is still largely beyond our understanding. In this review, a neuropsychological perspective on language impairments in SLI is taken, focusing specifically on executive functioning (EF) in preschoolers (age range: 2.6-6.1 years) with SLI. Based on the studies described in this review, it can be concluded that similar to school-aged children with SLI, preschoolers with SLI show difficulties in working memory, inhibition and shifting, as revealed by both performance based measures and behavioral ratings. It seems plausible that a complex, reciprocal relationship exists between language and EF throughout development. Future research is needed to examine if, and if yes how, language and EF interact in SLI. Broad neuropsychological assessment in which both language and EF are taken into account may contribute to early detection of SLI. This in turn can lead to early and tailored treatment of children with (suspected) SLI aimed not only at stimulating language development but also at strengthening EF.

Executive dysfunctions, reading disabilities and speech-language pathology evaluation

BACKGROUND

Many students with reading disabilities exhibit persisting reading problems despite intervention. The crucial difference between effective and struggling readers is their executive functions (EFs), and improved functions impact positively on learning to read and reading to learn.

OBJECTIVES

Firstly, to show that high-risk and struggling students' persisting language and reading difficulties are accompanied by executive dysfunctions. Secondly, to present one student's daily struggles at school in a narrative based on teacher, parent and child interviews.

METHOD

This retrospective study is based on speech-language pathology (SLP) evaluations of a clinical sample of 23 girls and boys aged 6-16 from a range of middle class families. While language and reading evaluations were tailored to the students' particular situation, i.e. age, grade, languages or complaint, EFs were examined in all with the Behaviour Rating Inventory of Executive Function teacher questionnaire.

RESULTS

Virtually all students exhibited executive dysfunctions, and many showed a high risk of attention deficit hyperactivity disorders.

CONCLUSIONS

This study demonstrated that inclusion of EFs in SLP evaluations is valuable in uncovering executive dysfunction comorbidity that may underlie persisting reading disorders. It is proposed that speech-language pathologists explicitly and routinely braid language and reading with EFs in their evaluations so to effectively predict, uncover and prevent persisting reading disabilities in students.

Lexical learning and lexical processing in children with developmental language impairments

Lexical skills are a crucial component of language comprehension and production. This paper reviews evidence for lexical-level deficits in children and young people with developmental language impairment (LI). Across a range of tasks, LI is associated with reduced vocabulary knowledge in terms of both breadth and depth and difficulty with learning and retaining new words; evidence is emerging from on-line tasks to suggest that low levels of language skill are associated with differences in lexical competition in spoken word recognition. The role of lexical deficits in understanding the nature of LI is also discussed.

Somatostatin receptor subtypes 2 and 5 are associated with better survival in well-differentiated endocrine carcinomas

The majority of gastroenteropancreatic well-differentiated endocrine carcinomas (WDEC) express somatostatin receptors (SSTR). To correlate the expression of SSTR subtypes by reverse transcriptase-polymerase chain reaction (RT-PCR) with clinicopathological features and survival in a group of WDEC patients, 42 WDEC tissue specimens from 33 patients were analysed. All patients were treated with somatostatin analogues and had a median follow-up period of 45 months (range 6-196). Neither SSTR2 and SSTR5 expression nor Ki-67 level alone correlated with survival. A significantly better survival rate was observed in patients with tumours expressing SSTR2, SSTR5 and Ki-67 <2%, compared to those with SSTR2- and SSTR5-negative tumours and Ki-67 >or=2% (p < 0.038), with 5-year survival rates of 91 vs. 43%, respectively. Expression of SSTR2 and SSTR5 appears to play a positive prognostic role, possibly correlated with the high affinity that the available somatostatin analogues display for these 2 specific SSTR subtypes.