Using language for social purposes can be a real challenge for children with autism spectrum disorder (ASD) and developmental language disorder (DLD). Despite the positive effects of the Pragmatic Intervention Programme (PICP) already known in both populations, the effects needed to be established with a larger sample and analysed separately for each condition. This study aims to analyse the effectiveness of PICP on preschool-age children with ASD or DLD with pragmatic impairment. A non-randomised controlled trial was conducted. Thirty-six children were assigned to experimental (n = 22) or control group (waiting list) (n = 14). Each child attended 24 PICP-based intervention sessions provided by a speech and language therapist. The primary outcome measure was a Goal Attainment Scale (GAS). The secondary outcomes were Escala de Avaliação de Competências Comunicativas (EAC) and Teste de Linguagem – Avaliação da Linguagem Pré-Escolar (TL-ALPE). The results indicated that all children achieved clinically significant progress in GAS after intervention. Statistically significant differences were observed between the experimental and control groups in the EAC and TL-ALPE after post-intervention assessment (T2). These results reinforce that PICP improves language in preschool-age children with ASD and DLD with pragmatic impairment. Differences between conditions and implications for future studies are discussed.
Children diagnosed with autism spectrum disorder (ASD) and developmental language disorder (DLD) often have difficulties using language in social contexts. An intervention programme for preschool-age children with pragmatic difficulties, called Pragmatic Intervention Programme (PICP), showed positive effects for these children. However, it was important to confirm these effects with a larger group and analyse them separately for each condition. In this study, the effectiveness of the PICP was analysed in preschool-age children with ASD or DLD with difficulties in using language in social contexts. The study was carried out with 36 children. Twenty-two were allocated to an experimental group to receive the PICP-based intervention first, and 14 children were assigned to a control group (waiting list). Each child attended 24 PICP-based intervention sessions provided by a speech and language therapist. Progress was measured using a Goal Attainment Scale (GAS) and other language assessment instruments. The results showed that all children in the experimental group made significant progress in their language competencies, compared to the control group after the intervention. This study confirms that the PICP is effective in improving language competencies in preschool-age children with ASD and DLD with difficulties in using language for social purposes, regardless of their condition. These results emphasise the importance of tailored interventions for these children and point to areas for further research.
Autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition characterised by persistent difficulties in social communication and social interaction and restricted repetitive behaviours, activities, or interests (American Psychiatric Association, 2022). According to recent data collected in 2020 through the Centres for Disease Control and Prevention, it was estimated that 1 in 36 children were diagnosed with ASD at age 8 (Maenner et al., 2023) which represents an increase of approximately 20% since 2018. Current evidence from epidemiological studies in Europe also supports an increase in ASD prevalence (Bougeard et al., 2021).
Developmental language disorder (DLD), in turn, is a common and heterogeneous neurodevelopmental disorder that occurs during childhood (Bishop, 2017; Georgiou & Spanoudis, 2021) and affects 3% to 7% of children (Norbury et al., 2016). The term applies to significant difficulties in one or more language domains, in expressive and/or receptive language that affect communication and learning without an associated biomedical condition (Bishop et al., 2016, 2017).
Using language for social purposes (pragmatics) can be a real challenge for children with ASD and DLD (Cummings, 2017). Considering the long-term impact that pragmatic language difficulties may have on learning, socialisation and mental health, early, effective, and evidence-based interventions are crucial (Cummings, 2017). Several intervention approaches have been proposed to support pragmatic language development. Some of these include Social Scripts (Nelson, 1978), Social Stories (Gray & Garand, 1993), Comic Strip Conversations (Gray, 1994), Social Use of Language Programme (Rinaldi, 1995), Score Skills Strategy (Vermon et al., 1996), Social Thinking (Winner & Crooke, 2009), Social Communication Intervention Project (Adams et al., 2012), Building Blocks Programme (Roberts et al., 2011), JASPER (Kasari et al., 2006), Mind Reading (Thomeer et al., 2015), and Pragmatic Intervention Programme (PICP) (Pereira et al., 2019, 2021).
A systematic review of the efficacy, targets, mode of delivery, and intensity of pragmatic interventions for children with DLD was conducted by Jensen de López et al. (2022). Eleven studies were included. The results revealed that the main targets of the interventions were conversation and narrative skills. The type of intervention was both direct and indirect, and the dominant mode of delivery was individual. Approximately half of the interventions (six) were set in educational settings. The agent of delivery was a non-specialist in nine of the total pragmatic language interventions included. The session length ranged from 15 to 150 minutes, dose frequency ranged from one to four times per week, and duration intensity ranged from 1 to 18 weeks. The total number of intervention sessions ranged from 4 to 32.
In 2017, Parsons et al. (2017) published a systematic review with a meta-analysis of pragmatic language interventions for autistic children. The authors reported that across the 22 included studies, the majority (71%) of the pragmatic language interventions were set in clinics. Non-verbal communication was the most targeted competency. In 13 studies, the intervention was delivered in groups. The most mentioned frequency and total intervention duration were weekly and 12 weeks, respectively. Considering that pragmatic language was often assessed in the context in which the intervention was given or through a decontextualised assessment instrument, conclusions were not drawn about the generalisation of skills following these interventions. The authors emphasise the importance of having instruments that capture the complex nature of social interactions so that researchers and clinicians can measure pragmatic changes after intervention, as well as skills maintenance and generalisation (Parsons et al., 2017).
Pragmatics is a highly dynamic and context-dependent language domain. Given its complex nature, pragmatic language can be particularly difficult to evaluate using standardised instruments (Shipley & McAfee, 2021), although this method is the most frequently used to evaluate children’s language (Binns & Cardy, 2019). Recent literature has shown that several studies have used standardised instruments to measure the effects of pragmatic interventions for children with DLD (Pereira & Lousada, 2023) and ASD (Pereira et al., submitted). Furthermore, it was identified that these instruments present some evidence of validity and reliability, but none report responsiveness, which could influence a clear interpretation of the results (Pereira & Lousada, 2023; Pereira et al., submitted). This highlights the fact that several parameters must be considered when selecting an outcome measure (Denman et al., 2017) and analysing the results of an intervention study (Pereira & Lousada, 2023).
Beyond standardised instruments, parent/teacher reports and structured/direct observations have also been used to assess pragmatic language (Norbury, 2014). However, the potential bias introduced emphasises the need for further development around pragmatic language measurement. Accordingly, instruments that capture the complex nature of social interactions are required so that researchers and clinicians can obtain unbiased measurements of pragmatic language (Jensen de López et al., 2022; Parsons et al., 2017; Pereira & Lousada, 2023).
The need to have an outcome to measure the effects of a pragmatic intervention with the potential to show clinically significant change and be intimate with the intervention content led Adams and Gaile (2020) to the development and test of an adapted Goal Attainment Scale (GAS) for children with pragmatic impairment. The authors proposed a system based on a 7-point scale to demonstrate the hypothesised steps to achievement, the expected achievement, and descriptions of achievement over and above the expected level and stated that GAS is an acceptable and feasible primary endpoint for assessing the outcomes of a complex social communication intervention for children with pragmatic difficulties. Adams and Gaile (2020) also considered that GAS may be useful for measuring outcomes of manualised interventions that require individualisation and whose populations are heterogeneous.
Despite the similarities and differences described in the literature (Andreou et al., 2022), fewer studies have analysed and compared the practice patterns in the field of pragmatics regarding these two neurodevelopmental disorders, DLD and ASD. To address this knowledge gap, a cross-sectional survey was carried out in Portugal to explore the current practices of Speech and Language Therapists (SLTs) working with preschool-age children with pragmatic impairment arising from ASD, DLD or both. Assessment and intervention practices were analysed. In this study, 351 SLTs have participated. Of these, 81.5% (n = 286) reported working or had worked with preschool-age children with pragmatic impairment arising from ASD (32.2%, n = 92), DLD (10.8%, n = 31) or both (57%, n = 163) (Pereira et al., 2024). In Pereira et al.’s study (2024), only the data from the respondents who were currently working or had worked with preschool-age children with pragmatic impairment arising from ASD (32.2%, n = 92) or DLD (10.8%, n = 31) were described and compared.
The survey reported that the majority of Portuguese SLTs perform an informal assessment to evaluate pragmatic language skills, regardless of the neurodevelopmental condition. The authors discussed this finding considering the complex nature of pragmatics (which may lead SLTs to prefer informal to standardised assessment) and the lack of pragmatic assessment instruments validated and standardised for European Portuguese (the Language Use Inventory (Guimarães et al., 2013; O’Neill, 2009) was the only one available at the time of data collection) (Pereira et al., 2024).
Considering intervention, similarities and differences were found in Portuguese SLTs’ practices. The similarities included not following any specific method, programme or approach, type of intervention (mixed), frequency (weekly) and length of the sessions (30–45 min and 45 min to 1 hour). Although the percentage of SLTs who do not follow any specific method, programme or approach was over 90%, those who mentioned using it also mentioned the PICP (Pereira et al., 2024).
The context of the intervention and the communicative partners involved differed. The most reported intervention context by the SLTs who were working or had already worked with children with ASD was the clinic and the communicative partners most involved were parents/caregivers. On the other hand, the most reported intervention context by SLTs who were only working or had already worked with children with DLD was school, and the most involved communicative partners were Early Childhood Educators (ECEs). The authors mentioned that despite the school being one of the privileged settings of action for Portuguese SLTs, peers are not the most present communicative partners in the intervention process, giving way to parents or other caregivers (Pereira et al., 2024). The literature suggests that the use of typically developing peers in group interventions increases the social interactions of children and adolescents with ASD, and promotes skill maintenance and generalisation (Watkins et al., 2015). Therefore, Pereira et al. (2024) highlighted that future intervention studies may benefit from including typically developing peers. Bauminger-Zviely et al. (2020) reinforces that the exposure of the school community and parents to the intervention should further increase skills’ generalisation.
In Portugal, the PICP (Pereira et al., 2019, 2021) is the only intervention programme developed and content-validated for preschool-age children with pragmatic impairment. It includes 11 competencies, namely: (1) eye contact, (2) joint attention, (3) turn-taking, (4) communicative response, (5) communicative initiative, (6) communicative functions, (7) comprehension and expression in verbal and non-verbal communicative contexts, (8) cohesion, (9) inferential comprehension, (10) conversation, and (11) figurative language. It advocates that these skills should be worked on with different communicative partners (e.g. peers and ECEs) and in multiple contexts (e.g. home, early childhood educational settings) to promote skills generalisation.
The effects of the PICP were preliminarily studied based on the results of an ongoing non-randomised controlled trial with 20 preschool-age children (with pragmatic impairment arising from ASD or DLD). In the study, the children were allocated into experimental or control groups, so both groups had children with both conditions. Each child received 24 PICP-based intervention sessions provided by an SLT, biweekly, for 1 hour, in early childhood educational settings. All children were assessed before and after the intervention in the experimental group. The primary outcome measure was the GAS and the secondary outcomes included Escala de Avaliação de Competências Comunicativas (Communicative Skills Assessment Scale) (EAC) (Seabra et al., 2021) (rated by parents and ECEs) and Teste de Linguagem – Avaliação da Linguagem Pré-Escolar (Preschool Language Test) (TL-ALPE) (Mendes et al., 2014) (applied by an SLT blind to the aims of the study). The GAS results showed that all children in the experimental group made progress and met expectations for at least two of three goals. For secondary outcomes and considering the small sample size, the non-parametric Mann–Whitney U test was used for group comparisons. Considering the difference between pre- and post-intervention assessments, the results were statistically significant for EAC (rated by parents and ECEs) and TL-ALPE (Pereira et al., 2022).