A Multi-Method Investigation of Pragmatic Development in Individuals With Down Syndrome

Pragmatic competence in people with dual diagnosis: down syndrome and autism spectrum disorder

BACKGROUND

Pragmatics is an area that can be affected in a wide variety of disorders. In this sense, Syndromic Autism is defined as a disorder in which a causal link is established between an associated syndrome and Autism Spectrum Disorder (ASD). Likewise, Down Syndrome (DS) is one of the main genetically based syndromes in which ASD is described as one of its possible manifestations. In this direction, people with DS are described as social beings whereas in ASD there seems to be a specific alteration of this domain.

METHODS

In this study, pragmatic performance was analysed in a sample of 72 participants, where comparisons were made between the scores obtained by children with ASD (n = 24), with DS (n = 24) and with DS + ASD (n = 24).

RESULTS

The Social Communication Questionnaire (SCQ), the Block Objective and Criterial Language Battery (BLOC-SR) and the Neuropsychology subtest (NEPSY-II) aimed at Theory of Mind (ToM) identified significant differences between the groups. However, two-to-two comparisons reported no significant differences between DS and DS + ASD.

CONCLUSIONS

Although several studies report differences between the three proposed groups, our data seem to suggest that ASD symptomatology in DS is associated with Intellectual Developmental Disorder (IDD). However, the lack of solid scientific evidence regarding comorbid diagnosis makes further research along these lines indispensable.

TRIAL REGISTRATION

This study was approved by the Ethics Committee for Social Research at UCLM with reference CEIS-704,511-L8M4.

A longitudinal investigation of pragmatic language across contexts in autism and related neurodevelopmental conditions

Background

Pragmatic language, or the use of language in social contexts, is a critical skill in daily life, supporting social interactions and the development of meaningful social relationships. Pragmatic language is universally impacted in autism spectrum disorder (ASD) and pragmatic deficits are also common in other neurodevelopmental conditions, particularly those related to ASD, such as fragile X syndrome (FXS). This study used a multi-method, longitudinal approach to characterize potentially unique pragmatic profiles across different neurodevelopmental disabilities, and across contexts that varied in degree of social demand. The utility of computational linguistic analyses, as an efficient tool for capturing pragmatic abilities, was also explored.

Methods

Pragmatic skills of boys with idiopathic ASD (ASD-O, n = 43), FXS with and without ASD (FXS-ASD, n = 57; FXS-O, n = 14), Down syndrome (DS, n = 22), and typical development (TD, n = 24) were compared using variables obtained from a standardized measure, narrative, and semi-naturalistic conversation at up to three time points.

Results

Pragmatic language was most significantly impacted among males with ASD-O and FXS-ASD across all three contexts, with more difficulties in the least structured context (conversation), and also some differences based on FXS comorbidity. Patterns of group differences were more nuanced for boys with FXS-O and DS, with context having less of an impact. Clinical groups demonstrated minimal changes in pragmatic skills with age, with some exceptions. Computational language measurement tools showed some utility for measuring pragmatic skills, but were not as successful as traditional methods at capturing differences between clinical groups.

Conclusion

Overlap and differences between ASD and other forms of neurodevelopmental disability in general, and between idiopathic and syndromic ASD in particular, have important implications for developing precisely tailored assessment and intervention approaches, consistent with a personalized medicine approach to clinical study and care in ASD.

Using the Social Skills Improvement System (SSiS) Rating Scales to assess social skills in youth with Down syndrome

Introduction and Methods

This study provides preliminary data on the Social Skills Improvement System (SSiS) Rating Scales Parent Form to measure social skills in a sample of 124 children and adolescents with Down syndrome (DS) ages 6–17 years.

Results

Overall, participants demonstrated relatively mild symptoms, with the sample’s average standard score falling within 1 standard deviation from the mean of the normative sample for the social skills (M = 92, SD = 15) and problem behaviors (M = 104, SD = 12) domains (normative sample M = 100, SD = 15 for both domains). However, a wide range of scores was observed across the sample for the composite and subscale scores. Differential patterns were also observed by subscale. For some subscales (i.e., Cooperation, Assertion, Responsibility, Engagement, Externalizing, Hyperactivity/Inattention, and Autism Spectrum), a disproportionate number of participants scored in the below average (i.e., lower levels of social skills) or above average (i.e., more symptomatic in problem behaviors or autism spectrum) range relative to the normative sample; for other subscales (i.e., Communication, Empathy, Self-Control, Bullying, and Internalizing), participants’ score distribution aligned more closely to that of the normative sample. SSiS composite scores correlated in the expected directions with standardized measures of autism characteristics, executive function, and expressive language.

Discussion

This study provides some of the first evidence validating the use of the SSiS in youth with DS, filling a gap in standardized measures of social functioning in this population.

Variation in morpho-lexical development within and between diagnoses in children with neurodevelopmental disorders

While primary diagnosis is only one aspect of the presentation of a child with neurodevelopmental delay/disorder, the degree to which early expressive language reflects diagnostic divisions must be understood in order to reduce the risk of obscuring clinically important differences and similarities across diagnoses. We present original data from the New Zealand MacArthur-Bates Communicative Development Inventory (NZCDI) from 88 English-speaking children aged 2;6 to 5;6 years receiving multidisciplinary intervention within a single family-centered program. The children had one of six pediatrician-assigned genetic or behaviorally determined diagnoses: Down syndrome (DS); motor disorders (cerebral palsy and developmental coordination disorder); global development delay; disorders of relating and communicating (R&C); other genetically defined diagnoses; or language delay due to premature (PREM) birth. Morphological and lexical development were compared within and across diagnostic groups, using both data visualization and mixed-effects modeling. Groups varied in the amount of variation within and between them, but only prematurity reached significance, in interaction with age, as a predictor of morpho-lexical scores. Further analysis of longitudinal data available from a subset of the sample (n = 62) suggested that individual trajectories of vocabulary growth could not be reliably predicted by diagnosis. Moreover, the distribution of word types (nouns, predicates, etc.) only distinguished PREM children with language delay from those with DS and those in the R&C group. There were strong similarities in early morpho-lexical development across these clinical populations, with some differences. These findings align with research and clinical approaches which accommodate individual variation within diagnosis, and broad similarities across diagnostic groups.

The association between expressive language skills and adaptive behavior in individuals with Down syndrome

The primary goal of this study was to determine whether expressive language skills contribute to adaptive behavior (e.g., socialization and daily living skills) in children, adolescents, and young adults with Down syndrome (DS) whilst controlling for age and nonverbal cognitive ability. Expressive language was assessed using the psychometrically validated Expressive Language Sampling (ELS) conversation and narration procedures. The language produced was transcribed and analyzed to yield measures of expressive vocabulary, syntax, and intelligibility. Socialization and daily living skills of participants with DS were measured with the Vineland Adaptive Behavior Scales, 2nd edition (VABS-2) parent/caregiver rating form. Our results show that the three ELS measures were significantly correlated with multiple measures from the VABS-2 when controlling for age. Several correlations remained significant even when nonverbal cognitive ability was included as a control variable. Our results suggest that expressive language skills contribute to adaptive behavior in children, adolescents, and young adults with DS regardless of age and some of these associations are not explained solely by overall cognitive delays. Further studies including longitudinal data are needed to extend our results.

A Longitudinal Study of Parent-Child Interactions and Language Outcomes in Fragile X Syndrome and Other Neurodevelopmental Disorders

Difficulties with pragmatic language (i.e., language in social contexts, such as conversational ability) are a noted characteristic of the language profiles of both fragile X syndrome (FXS) and autism spectrum disorder (ASD), conditions which show significant phenotypic overlap. Understanding the origins and developmental course of pragmatic language problems in FXS and other developmental conditions associated with language impairment is a critical step for the development of targeted interventions to promote communicative competence across the lifespan. This study examined pragmatic language in the context of parent-child interactions in school-age children with FXS (who did and did not meet ASD criteria on the ADOS; n = 85), idiopathic ASD (n = 32), Down syndrome (DS; n = 38), and typical development (TD; n = 39), and their parents. Parent-child communicative interactions were examined across multiple contexts, across groups, and in relationship to pragmatic language outcomes assessed 2 years later. Results showed both overlapping and divergent patterns across the FXS-ASD and idiopathic ASD child and parent groups, and also highlighted key differences in pragmatic profiles based on situational context, with more pragmatic language difficulties occurring for both ASD groups in less structured interactions. Differences in parental language styles during parent-child interactions were associated with child language outcomes, likely reflecting the complex interplay of discourse style inherent to a parent, with the inevitable influence of child characteristics on parent language as well. Together, findings help delineate the dynamic and multifactorial nature of impaired pragmatic skills among children with FXS and other neurodevelopmental disorders associated with language impairment, with potential implications for the development of targeted interventions for pragmatic communication skills.

Narrative Abilities of Adults' With Down Syndrome as a Window to Their Morphosyntactic, Socio-Cognitive, and Prosodic Abilities

Down syndrome (DS) is the most common developmental disorder characterized by mild to moderate intellectual disability. Several studies have reported poor language and prosodic skills and contradictory results regarding individuals’ with DS socio-cognitive skills, whereas most of them have focused on children with DS. The present study attempts to explore adults’ with DS language, socio-cognitive and prosodic abilities via the use of story-retellings. Twenty adults with DS and two groups of TD children, one matched to their expressive vocabulary (TD-EVT) and the other matched to their non-verbal mental age (TD-RCPM), took part in the present study. Participants listened to a story while viewing a wordless picture PowerPoint presentation on a computer screen, and then, they were instructed to retell the story while viewing the pictures for a second time. Each participant listened to two stories, one with “lively” and one with “flat” prosody. Results revealed that adults’ with DS performance was comparable with the one presented by the TD-RCPM group, whereas the TD-EVT group performed significantly better in almost all variables. Individuals’ with DS re-narrations, however, contained significantly less complement clauses and internal state terms (related or not related to Theory of Mind–ToM) compared to the re-narrations of both control groups. In contrast, the group with DS performed similarly to both control groups in comprehension questions related to main characters’ internal state terms and significantly better compared to the TD-RCPM group in questions related to ToM. In terms of prosody, all three groups performed significantly better on story structure and comprehension questions when prosody was “lively” compared “flat” prosody. DS group’s re-narrations did not contain enough internal state terms, not due to their inability in recognizing them, but due to their poor morphosyntactic abilities, which did not allow them to find the proper means to express the main characters’ internal states. Prosody facilitated participants with DS in the comprehension and re-narration. This suggests that intervention programs based on prosody could support the language skills of adults with DS.

Systematic Review of Recent Pediatric Down Syndrome Neuropsychology Literature: Considerations for Regression Assessment and Monitoring

OBJECTIVES

To conduct a systematic review of recent pediatric Down syndrome (DS) neuropsychology research that may be useful to clinicians and researchers examining regression in this population.

METHODS

We reviewed original peer-reviewed articles published between 2013 and 2018 studying neuropsychological profiles in DS.

RESULTS

Thirty-one articles (of 1231 included in the original search) passed all inclusion criteria, were evaluated for bias, and were included in the analysis.

CONCLUSION

Findings argued against a single "DS profile" and revealed multiple within-group differences as well as expected and unexpected differences relative to typically developing children and children with other intellectual and developmental disabilities. Areas identified as most germane to regression monitoring included working memory, inhibition, letter and word identification, navigational route learning, motor skills (when strong at baseline), single word receptive/expressive vocabulary, and adaptive function.

Expressive language development in adolescents with Down syndrome and fragile X syndrome: change over time and the role of family-related factors

BACKGROUND

It is well known that individuals with Down syndrome (DS) or fragile X syndrome (FXS) demonstrate expressive language difficulties beginning early in childhood. It is less clear, however, whether expressive language skills change during the adolescent period in these individuals, and if any of these changes are syndrome specific. Studying this, as well as the role of maternal and family-related factors in expressive language development, may provide the foundation for efficacious interventions for adolescents with DS or FXS.

METHODS

In this study, we examined expressive language trajectories, assessed through conversation and narration, in 57 adolescent males with intellectual disability (ID) (20 DS and 37 FXS) in relation to the diagnostic group (DS vs. FXS) and family-related factors (maternal IQ, maternal psychological distress, closeness in the mother-child relationship, family income, and maternal and paternal education) after adjusting for chronological age (CA) and nonverbal cognition.

RESULTS

Changes over repeated annual assessments for males with DS or FXS were observed only during conversation, such as an increase in talkativeness, but a decrease in syntax complexity and lexical diversity. We found a diagnosis-related effect in the change over time in conversational talkativeness favoring those with FXS. Finally, a closer mother-child relationship predicted less decrease over time in lexical diversity during conversation, and participants of mothers who graduated college showed a greater increase in conversational talkativeness over time compared to those of mothers with a high school education.

CONCLUSIONS

Our results suggest that, during the adolescent period for males with DS or FXS, there is an increase in the amount of talk produced in conversational contexts, but also a decrease in the quality of the language produced. In addition, our results indicate syndrome-specificity for aspects of expressive language development and reinforce the protective role of family-related factors.

Relations between Everyday Executive Functioning and Language in Youth with Down Syndrome and Youth with Autism Spectrum Disorder

Language and executive functioning are major impairments in many neurodevelopmental disorders, but little is known about the relations between these constructs, particularly using parent-report. Thus, the current research sought to examine relations between executive function and language in two groups - Down syndrome (DS; n=41; Mage = 11.2) and autism spectrum disorder (ASD; n=91; Mage = 7.7). Results were as follows: in DS, executive function predicted pragmatic, but not structural language after covarying for age, sex, and social functioning; in ASD, executive function predicted both. Findings highlight the interrelatedness of language and executive functioning and may have implications for intervention development.

The Social Responsiveness Scale (SRS-2) in school-age children with Down syndrome at low risk for autism spectrum disorder

BACKGROUND AND AIMS

Little is known about how autism spectrum disorder (ASD) symptoms present in individuals with Down syndrome (DS). Some behaviors may be symptomatic of comorbid ASD or more broadly representative of the DS phenotype. A prior research study documented elevated ASD-like symptoms in adolescents and young adults with DS without comorbid ASD, using a common ASD risk screening tool-the Social Responsiveness Scale (SRS). The current study applied a similar approach to younger children with DS using the SRS-2. The primary aim was to document patterns of ASD-like symptoms in children with DS at low risk of comorbid ASD to distinguish the symptoms that may be present across DS in general.

METHODS

SRS-2 standard scores were analyzed in a sample of 40 children with DS, 6-11 years old, who were considered to be at low risk for ASD based on the Social Communication Questionnaire (SCQ) screener. Other developmental characteristics (i.e., age, nonverbal IQ, expressive language), social skills, and problem behaviors were also examined across the sample.

RESULTS

SRS-2 scores were significantly elevated in this sample compared to the normative population sample. A pattern of ASD-like symptomatology was observed across SRS-2 subdomains. These findings were similar to the findings of the prior study. However, nuanced differences were observed across the two samples that may represent developmental differences across different ages in this population.

CONCLUSIONS

Replicating and extending a prior study's findings, certain ASD-like behaviors may occur in individuals with DS who are at low risk for comorbid ASD.

IMPLICATIONS

Understanding the pattern of ASD-like behaviors that occur in children with DS who are at low risk for comorbid ASD will help clinicians in screening and identification efforts. In particular, it will lead to better specification of the behaviors or symptoms that are not characteristic of the DS phenotype and thus are red flags for comorbid ASD in this population.

Longitudinal analysis of communication repair skills across three neurodevelopmental disabilities

BACKGROUND

This study is a longitudinal follow-up to prior work examining the important pragmatic skill of communication repair (i.e., the ability to respond effectively to a request for clarification of an unclear message) across three neurodevelopmental disabilities in which language skills are impaired: fragile X syndrome with and without autism spectrum disorder (FXS-ASD; FXS-O), idiopathic ASD (ASD-O), Down syndrome (DS) and controls with typical development (TD). Prior work examining communication repair skills at younger ages indicated impairments in boys with FXS-ASD and ASD-O, with females performing comparably with each other across groups.

AIMS

To characterize communication repair skills in young individuals with FXS-ASD, FXS-O, ASD-O, DS and TD, across groups and over development. A secondary aim included documenting sex differences in FXS (with and without ASD) and DS.

METHODS & PROCEDURES

Sixty young individuals with FXS-ASD (49 males, 11 females), 38 with FXS-O (13 males, 25 females), 38 with ASD-O (males only), 42 with DS (21 males, 21 females) and 41 with TD (21 males, 20 females) participated in the study, with a subsample reported on here who were retested at a second time point 2.7 years later on average. Participants completed a structured, picture-based task designed to assess the ability to repair breakdowns in communication. Participants' responses were compared across groups and sexes at the second time point, and interpreted with respect to previously published (Time 1) findings.

OUTCOMES & RESULTS

Key findings included that, with age, male groups (including those with FXS-ASD and ASD-O, who showed difficulty at Time 1) performed more comparably, decreasing their use of inappropriate responses, in spite of relatively little change observed in general cognitive or structural language abilities in the clinical groups. However, girls with FXS and DS became more non-responsive with age, and differences between boys and girls with FXS-ASD emerged over time as well.

CONCLUSIONS & IMPLICATIONS

Findings suggest that impairments in a critical pragmatic skill-the ability to repair communication breakdown-show significant change with age across three neurodevelopmental disabilities, with important sex-specific patterns. These developments were often observed in spite of a relative plateau in cognitive and language growth, suggesting that repair skills may be more malleable and therefore an excellent target for intervention. Findings not only inform the nature of pragmatic impairment across groups but also can importantly inform clinical practice, suggesting that clinicians should monitor pragmatic skills such as repairs throughout development and also consider the role of sex in clinical efforts.

ASD Comorbidity in Fragile X Syndrome: Symptom Profile and Predictors of Symptom Severity in Adolescent and Young Adult Males

Many males with FXS meet criteria for ASD. This study was designed to (1) describe ASD symptoms in adolescent and young adult males with FXS (n = 44) and (2) evaluate the contributions to ASD severity of cognitive, language, and psychiatric factors, as well as FMRP (the protein deficient in FXS). A few ASD symptoms on the ADOS-2 were universal in the sample. There was less impairment in restricted and repetitive behaviors (RRB) than in the social affective (SA) domain. The best predictor of overall ASD severity and SA severity was expressive syntactic ability. RRB severity was best predicted by the psychiatric factors. Implications for clinical practice and for understanding the ASD comorbidity in FXS are discussed.

A Multimethod Analysis of Pragmatic Skills in Children and Adolescents With Fragile X Syndrome, Autism Spectrum Disorder, and Down Syndrome

PURPOSE

Pragmatic language skills are often impaired above and beyond general language delays in individuals with neurodevelopmental disabilities. This study used a multimethod approach to language sample analysis to characterize syndrome- and sex-specific profiles across different neurodevelopmental disabilities and to examine the congruency of 2 analysis techniques.

METHOD

Pragmatic skills of young males and females with fragile X syndrome with autism spectrum disorder (FXS-ASD, n = 61) and without autism spectrum disorder (FXS-O, n = 40), Down syndrome (DS, n = 42), and typical development (TD, n = 37) and males with idiopathic autism spectrum disorder only (ASD-O, n = 29) were compared using variables obtained from a detailed hand-coding system contrasted with similar variables obtained automatically from the language analysis program Systematic Analysis of Language Transcripts (SALT).

RESULTS

Noncontingent language and perseveration were characteristic of the pragmatic profiles of boys and girls with FXS-ASD and boys with ASD-O. Boys with ASD-O also initiated turns less often and were more nonresponsive than other groups, and girls with FXS-ASD were more nonresponsive than their male counterparts. Hand-coding and SALT methods were largely convergent with some exceptions.

CONCLUSION

Results suggest both similarities and differences in the pragmatic profiles observed across different neurodevelopmental disabilities, including idiopathic and FXS-associated cases of ASD, as well as an important sex difference in FXS-ASD. These findings and congruency between the 2 language sample analysis techniques together have important implications for assessment and intervention efforts.

Specificity: A Phenotypic Comparison of Communication-Relevant Domains Between Youth With Down Syndrome and Fragile X Syndrome

Despite the shared presence of an intellectual disability (ID), there is a growing literature documenting important phenotypic differences between Down syndrome (DS) and fragile X syndrome (FXS). These conclusions, however, are based on a synthesis across studies, each of which typically includes only measures of a limited number of constructs, and with differing participant characteristics. Firmer conclusions regarding specific phenotypes require a single comprehensive multi-domain assessment of participants with the syndrome groups being well matched on chronological age (CA) and cognitive functioning. The current study was designed to fill this gap by assessing several important cognitive and behavioral domains relevant to communication, such as: structural language skills, false belief understanding, as well as pragmatics and behavioral difficulties, in 30 adolescents of both sexes with DS and 39 males with FXS, matched on CA and nonverbal (NV) cognition. After statistically controlling for NV cognition, we did not find significant syndrome differences in expressive and receptive structural language or false belief understanding. In contrast, participants with DS displayed less stereotyped language and fewer behavioral difficulties compared to males with FXS. Within-syndrome associations among the targeted domains are described. Finally, females with DS were less impaired than males with DS in almost all structural language domains, whereas no significant sex-related differences were observed in NV cognition, false belief understanding, pragmatics, or behavior. Clinical and methodological implications of the findings are discussed.

A Duck Wearing Boots?! Pragmatic Language Strategies for Repairing Communication Breakdowns Across Genetically Based Neurodevelopmental Disabilities

PURPOSE

The ability to repair breakdowns in communication is an important pragmatic language skill that helps to maintain clear and meaningful interactions. Examining this ability in genetically based neurodevelopmental disabilities in which pragmatics are affected can provide important information about the precise pragmatic skills impacted across different populations and also help to identify core mechanisms underlying pragmatic impairment that may inform tailored interventions.

METHOD

Individuals with idiopathic autism spectrum disorder (ASD-O; n = 40), fragile X syndrome with comorbid autism spectrum disorder (FXS-ASD; n = 62), FXS without ASD (FXS-O; n = 38), Down syndrome (DS; n = 43), and typical development (TD; n = 42) completed a picture description task in which an examiner prompted for clarification repeatedly to elicit communication repair attempts. Participants' response strategies were compared across diagnostic groups and by sex and examined in relationship to different cognitive abilities.

RESULTS

Relatively few group differences were observed in responses to requests for clarification overall. Males with ASD-O responded less to clarification requests than males with FXS-ASD and FXS-O, and males with FXS-ASD responded more inappropriately than males with ASD-O and DS. All male groups became less responsive to prompts for communication repair across the series of requests. Males with TD and FXS-ASD used less effective strategies than females.

CONCLUSION

All groups showed some proficiency in repairing communication breakdowns, although individuals with ASD-O and FXS-ASD demonstrated some key areas of difficulty, highlighting the importance of considering ASD symptomatology in assessment and treatment of males with FXS. Findings also suggest that, across groups, multiple requests for clarification may lead to disengagement from the interaction. Finally, correlated skills observed across groups could implicate different underlying skills related to communication repair abilities across groups.

Inferential language use by youth with Down syndrome during narration

We examined inferential language use by youth with Down syndrome (DS) in the context of narrative storytelling relative to younger typically developing (TD) children and same-aged peers with fragile X syndrome (FXS) matched on nonverbal cognitive ability level. Participants' narratives were coded for the use of different types of inferential language. Participants with DS used proportionately less inferential language overall relative to their counterparts with TD or FXS, although mean length of utterance accounted for group differences observed for the DS-TD group comparison only. Patterns of inferential language use varied across inferential subtypes and across participant groups, with mean length of utterance playing a significant role in group differences. These findings suggest potential syndrome specificity to the DS phenotype regarding impairments in inferential language use that can be partially explained by level of expressive syntactic ability and should be considered in future research. Clinical interventions within the DS population, therefore, should target to some extent the use of inferential language and complex sentence structure.