Pragmatic Language Impairment

Last time, I wrote about specific language impairment (SLI), which is a disorder affecting not a person’s speech ability (that’s speaking) but the disorder of language comprehension and expression (the way a person uses language). Now, maybe you read the latest DSM edition, DSM-5, where you encounter the disorder pragmatic language impairment or social (pragmatic) communication disorder[1].

Is this disorder the same as the specific language impairment (SLI)?

No. Actually, in my SLI article, pragmatic language impairment is under the more general SLI (For more about SLI and its subtypes, click my article here).

Now, what is pragmatic language impairment?

Pragmatic language impairment (PLI), also known as social (pragmatic) communication disorder (SCD), nonverbal learning disorder (NVLD) or semantic-pragmatic disorder (SPD not to be confused with sensory processing disorder), is an impairment in understanding pragmatic aspects of language.[1] Pragmatic language impairments are related to autism and Asperger syndrome, but also could be related to other non-autistic disabilities such as ADHD and intellectual disabilities.[1][2] People with these impairments have special challenges with the semantic aspect of language (the meaning of what is being said) and the pragmatics of language (using language appropriately in social situations).[1] This means a person having PLI can understand language literally but not figuratively. They also have difficulty in expressing language despite being able to speak and they are often mistaken as either shy, rude, or nervous even if they’re not feeling that way.

Image courtesy of speechbuddy.com. Pragmatic language impairment makes a child find it hard to understand and express social language that makes her mistaken as shy, rude, or nervous.

What are the symptoms of PLI?

According to Wikipedia, people with PLI have particular trouble understanding the meaning of what others are saying, and they are challenged in using language appropriately to get their needs met and interact with others.[1] Symptoms of PLI include[1]:

  • delayed language development
  • aphasic speech (such as word search pauses, jargoning, word order errors, word category errors, verb tense errors)
  • stuttering or cluttering speech
  • repeating words or phrases
  • difficulty with pronouns or pronoun reversal
  • difficulty understanding questions
  • difficulty understanding choices and making decisions.
  • difficulty following conversations or stories. Conversations are “off-topic” or “one-sided”.
  • difficulty extracting the key points from a conversation or story; they tend to get lost in the details
  • difficulty with verb tenses
  • difficulty explaining or describing an event
  • tendency to be concrete or prefer facts to stories
  • difficulty understanding satire or jokes
  • difficulty understanding contextual cues
  • difficulty in reading comprehension
  • difficulty with reading body language
  • difficulty in making and maintaining friendships and relationships because of delayed language development.
  • difficulty in distinguishing offensive remarks
  • difficulty with organizational skills

Oh… it’s really difficult, right? But wait, in order to better understand PLI, first, I’ll tell you what is the so-called “pragmatic language.” What is it by the way?

What is pragmatic language?

Pragmatics or social language use is the application of using language in social communication and situations. This means more than the proper way of saying hello and goodbye. Let’s quote from American Speech-Language-Hearing Association (ASHA)[3]:

You have invited your friend over for dinner. Your child sees your friend reach for some cookies and says, “Better not take those, or you’ll get even bigger.” You’re embarrassed that your child could speak so rudely. However, you should consider that your child may not know how to use language appropriately in social situations and did not mean harm by the comment.

An individual may say words clearly and use long, complex sentences with correct grammar, but still have a communication problem – if he or she has not mastered the rules for social language known as pragmatics. Adults may also have difficulty with pragmatics, for example, as a result of a brain injury or stroke.

Now, pragmatics have these properties[3]:

Three Major Communication Skills:

  • Using language for different purposes, such as
    • greeting (e.g., hello, goodbye)
    • informing (e.g., I’m going to get a cookie)
    • demanding (e.g., Give me a cookie)
    • promising (e.g., I’m going to get you a cookie)
    • requesting (e.g., I would like a cookie, please)
  • Changing language according to the needs of a listener or situation, such as
    • talking differently to a baby than to an adult
    • giving background information to an unfamiliar listener
    • speaking differently in a classroom than on a playground
  • Following rules for conversations and storytelling, such as
    • taking turns in conversation
    • introducing topics of conversation
    • staying on topic
    • rephrasing when misunderstood
    • how to use verbal and nonverbal signals
    • how close to stand to someone when speaking
    • how to use facial expressions and eye contact

Now, as ASHA has stated in their pragmatics article, these communication rules vary across cultures. This mieans, if a person with PLI lives in cultures with stricter social hierarchy and high nonverbal gestures (Asia, Arab countries) have a double whammy when it comes to PLI symptoms as people with PLI cannot read hidden social rules that makes them mistaken as rude or not respectful. If he or she is mistaken as rude in Western cultures (I will specify Anglo-Germanic culture as the main Western culture), then he or she will be more mistaken as very rude and insubordinate to social superiors in higher context cultures such as Asian and Arab cultures. This could be damaging to the person with PLI as no one can understand that the person with PLI has not mastered the “social aspects of language” and he or she does not look to have any noticeable learning disability (dyslexia) or neurological disorder (Tourette syndrome).

Image courtesy of talkingtalk.co.za. Children with PLI don’t know how to choose appropriate words at appropriate times. In this drawing, a mother tells her friend about her son swearing sentences.

People with PLI have fluent, complex and clearly articulated expressive language but exhibit problems with the way their language is used. These children typically are verbose. However, they usually have problems understanding and producing connected discourse, instead giving conversational responses that are socially inappropriate, tangential and/or stereotyped. They often develop obsessional interests but not as strong or eccentric as people with Asperger’s Syndrome or autism.[1]  This makes PLI often confused or mistaken as autism spectrum.

Is PLI a form of autism?

There is a debate whether PLI is a relative or is part of autism spectrum or not because of its symptom similarities. Nevertheless, PLI is distinguished from autism by the absence of any history (current or past) of restricted/repetitive patterns of interest or behavior.[1][4]

How is PLI presented?

PLI has more to do with communication and information processing than language. For example, children with semantic pragmatic disorder will often fail to grasp the central meaning or saliency of events. This then leads to an excessive preference for routine and “sameness” (seen in autism and Asperger’s Syndrome), as PLI children struggle to generalize and grasp the meaning of situations that are new; it also means that more difficulties occur in a stimulating environment than in a one-to-one setting.[1]

A further problem caused by PLI is the assumption of literal communication. This would mean that obvious, concrete instructions are clearly understood and carried out, whereas simple but non-literal expressions such as jokes, sarcasm and general social chatting are difficult and can lead to misinterpretation. Lies are also a confusing concept to children with PLI as it involves knowing what the speaker is thinking, intending and truly meaning beyond a literal interpretation.[1]

In short, people with PLI are often hypersensitive and look “immature” compared to their peers. They are often subjects to social isolation and bullying.

Image courtesy of PsychCentral. Children with PLI use language literally that they become sensitive to sarcasm or joke and may be subjects to bullying and social isolation.

Other features of PLI are the following[5]:

They often do not assume prior knowledge. So for example, one boy explained to me in minute detail how to wash a car, wrongly assuming that I needed (and wanted) the information and that I had never washed a car.

On the other hand, they may assume prior knowledge that the listener could not possibly have, and launch into a long disquisition without describing in sufficient detail the participants, location and general background of their story.

They can go on far too long telling stories, and include so much detail that the listener becomes disinterested.

Complications of PLI

Usually, when a person with PLI isn’t understood when communicating, this person (or child) may act out (yelling, kicking or throwing objects), which can be mistaken as misbehaving to parents, teachers, and peers (or colleagues). PLI deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.[6]

How is PLI diagnosed?

Delays in speech and language are hallmark signs of alarm to be brought in developmental pediatricians or language therapists. However, parents and doctors may not recognize the signs until years later.[7]

The American Speech-Language-Hearing Association (ASHA) recommends evaluating children in many different settings.[7][8] An evaluation by a speech-language pathologist, also referred to as a speech therapist, might include:

  • Observing your child in the classroom and at home
  • Interviewing your child’s teacher or caregiver or having her fill out a questionnaire
  • Performing formal one-on-one testing to assess your child’s language and communication skills

How is PLI Managed?

Since, PLI does not have any cure, management of the disorder is important as soon as possible to make improvements in the person’s communication skills.

Speech and language therapy is applied to the child with PLI. A speech therapist can work one-on-one with your child, helping him practice turn-taking, introducing and ending topics and other conversational skills. The therapist may use role-playing games and visuals, such as comic strips, to help your child learn strategies to manage social situations. The therapist also can train you in how to reinforce these skills at home.[7]

Special education is also preferred as it customizes the child’s learning. This may involve individualized education and speech therapy as well.

Unfortunately, the process of obtaining appropriate social pragmatic assessment in a school setting is often fraught with numerous difficulties. For one, due to financial constraints, not all school districts possess the appropriate, up to date pragmatic language testing instruments.[9] This makes PLI one of the most difficult disorders to understand. That’s why early identification, awareness, and most of all acceptance, are important in managing pragmatic language

Related disorders of PLI

PLI is not a lone neurodiverse condition. It is often presented with hyperlexia, dyspraxia, and higher functioning autism spectrum disorders such as Asperger syndrome and PDD-NOS.

Remember, if a child or adult has “immature” speech, that doesn’t necessarily mean he or she’s unprofessional or just kidding to a serious listener. It doesn’t necessarily mean also he or she has a very bad character. Maybe you should think first whether this person has pragmatic language impairment.

Also, if a person has PLI, this doesn’t necessarily mean he is weak all throughout. In fact, a person with PLI has super strength in analytical fields like mathematics, computer science, geography, astronomy, readinghistory, meteorology, botany, zoology, sports, politics or music.[1] These fields can be a good career choice for people with PLI.

References:

  1. https://en.wikipedia.org/wiki/Pragmatic_language_impairment
  2. Ahmed Mohammed Alduais, Rasha Mohammed Shoeib, Fayza Saleh Al Hammadi, Khalid Hassan Al Malki, Farah Hameid Alenezi (2012). “Measuring Pragmatic Language in Children with Developmental Dysphasia: Comparing Results of Arabic Versions of TOPL-2 and CELF-4 (PP and ORS Subtests)”.International Journal of Linguistics 4 (2): 475–494.doi:10.5296/ijl.v4i2.1685.
  3. http://www.asha.org/public/speech/development/Pragmatics/
  4. American Psychiatric Association, ed. (2013). “Social (Pragmatic) Communication Disorder, 315.39 (F80.89)”. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing. pp. 47–49.
  5. http://speech-language-therapy.com/~speech/index.php?option=com_content&view=article&id=103:spd&catid=11:admin&Itemid=120
  6. http://psychcentral.com/disorders/social-pragmatic-communication-disorder/
  7. https://www.understood.org/en/learning-attention-issues/child-learning-disabilities/communication-disorders/understanding-social-communication-disorder
  8. “Guidelines for Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span [Guidelines].” American Speech-Language-Hearing Association. 2006. http://www.asha.org/policy/gl2006-00049/#sec1.9.4
  9. http://www.smartspeechtherapy.com/what-are-social-pragmatic-language-deficits-and-how-do-they-impact-international-adoptees-years-post-adoption/
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