Pragmatic impairments in adults with childhood diagnoses of autism or developmental receptive...

Journal of Autism and Developmental Disorders, Vol. 23, No. 4, 1993

Pragmatic Impairments in Adults with Childhood Diagnoses of Autism or Developmental Receptive Language Disorder

Martin J. Eales 2 Institute of Psychiatry, De Crespigny Park, London.

Audiotaped conversational samples from adults diagnosed as having autistic disorders (n = 15) or developmental receptive language disorders (n = 17) in childhood were transcribed and analyzed using methods based on those of Bishop and Adams (1989). Subjects with autism showed substantially greater pragmatic impairment not explicable by generalized impairment of verbal skills. This was mainly due to autistic subjects' greater difficulty in forming context-relevant communicative intentions; in contrast, pragmatic impairments arising from failures in translating intentions into spoken utterances (i.e., impairments at the level of execution) did not distinguish between the groups. In both diagnostic groups, impairment in forming appropriate communicative intentions was closely related to more generalized impairment of reciprocal social behavior.

INTRODUCTION

Deviant language development has been a recognized feature of autism since the first descriptions of the syndrome (Kanner, 1946). One early formulation suggested that severe developmental language impairment with poor comprehension might be a key element explaining other

1The a u t h o r was supported by the Bethlem Royal and Maudsley Hospital Research Fund. Lynn Mawhood very kindly provided all of the primary data and extracted the conversational samples from her recorded interviews. I also thank Dorothy Bishop, Mary Crowson, Helen Eales, and Professor Sir Michael Rutter for advice and help in various aspects of the study.

2Address all correspondence to Martin J. Eales, Tone Vale Hospital, Norton Fitzwarren, Taunton, Somerset TA4 1DB, England.

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0162-3257/93/1200-0593507.00/0 @ 1993 Plenum Publishing Corporation

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features of the condition (Rutter, 1968). However, subsequent research has shown that the development of phonology and syntax in higher functioning autistic children, although delayed, follows a similar pattern to that of normal children (see Paul, 1987; Swisher & Demetras, 1985; Tager-Flusberg, 1989; Tager-Flusberg et al., 1990), and attention has increasingly focused on pragmatic aspects of language as an area of more specific impairment in autism (e.g., Baltaxe, 1977; Cromer, 1981; Landry & Loveland, 1988; Tager-Flusberg, 1981, 1989; Wetherby, 1986). This focus on the context- appropriate social use of language skills has accompanied a more general shift in theories of autism toward regarding social or social-cognitive impairments as more likely primary abnormalities (e.g., Baron-Cohen, Leslie, & Frith, i985; Fein, Pennington, Markowitz, Braverman, & Waterhouse, 1986; Frith, Morton, & Leslie, 1991; Rutter, 1983).

In this context pragmatic and social or social-cognitive deficits in autism have usually been seen as involving the same or at least very closely related areas of functioning (Baron-Cohen, 1988; Goodman, 1989; Tager- Flusberg, 1989). However, an alternative view, considering autism alongside a broader range of disorders, has suggested that pragmatic and social impairments are separate and at least partly dissociable (Bishop, 1989; Bishop & Rosenbloom, 1987; Rapin & Alien, 1983, 1987), and that pragmatic impairments comparable with those seen in autism can occur in the absence of the more pervasive social impairments characteristic of that condition. This might indicate that they have a more specifically linguistic basis.

In evaluating (even reconciling) these views, two points need to be appreciated. First, the term "pragmatics" is given a very wide reference by some authors, sometimes even approximating in meaning to "'social behavior," in which case any differentiation between pragmatic impairment and deficiencies in more general social skills is precluded. Second, even where, as in the present paper, the term is used in the more restricted sense cus- tomary in the linguistic literature (see Levinson, 1983), pragmatic aspects of language do not depend on a unified or coherent functional system but require the concerted use of a wide range of cognitive skills, both linguistic and nonlinguistic (phonology, syntax, vocabulary; attention and memory; "high-level" language skills in areas such as speech planning and the use of discourse devices; general reasoning ability; social-cognitive skills), which may be disrupted in a variety of different ways. Pragmatic impairments are therefore likely to be heterogeneous in terms of the functional deficits or abnormalities that underlie them, as reflected in the wide range of different disorders in which they have been shown to occur (e.g., Bishop, 1989; Fey & Leonard, 1983; Prutting & Kirchner, 1987; Swisher & Pinsker, 1971; van der Gaag, 1989). Progress in explaining these impairments requires their disaggregation into categories that are not only empirically distinguishable

Pragmatic Impairments in Adults with Childhood Diagnoses of Autism or RLD 595

but are likely to arise from different functional bases, as indicated, for example, by differences in their associations with diagnostic or other variables.

The present study explored the factors associated with a range of pragmatic impairments in a well-documented series of young adults, of normal nonverbal intelligence, who had received a childhood diagnosis of autism or severe specific developmental language disorder. Pragmatic assessment was based on a set of methods introduced by Bishop and Adams (1989) in their study of semantic-pragmatic language disorders in children. Particular attention was given to the separation of types of impairment likely to have different origins, and after presenting general aspects of the method of the study, the paper is divided into two sections: the first ana- lyzes the relationship of pragmatic impairments to diagnostic and other variables using global pragmatic indices derived directly from Bishop and Adams's methods; the second section builds on this earlier analysis by presenting a new method for disaggregating these pragmatic impairments into different subtypes and showing that these are related differently to the other variables considered in the study.

M E T H O D S

Subjects

The subjects were drawn from a long-term comparative study of autism and severe developmental receptive language disorder; the design of the study, and the methods used in recruitment and diagnosis of subjects have been described in previous papers comparing the two groups in childhood, adolescence, and early adult life (Bartak, Rutter, & Cox, 1975; Cantwell, Baker, Rutter, & Mawhood, 1989; Rutter, Mawhood, & Howlin, 1992). Subjects with autism had met the diagnostic criteria of Rutter (1978), while those in the language disorder group had presented in childhood with a severe delay in acquisition of spoken language, involving a serious deficit in the understanding of language, not due to deafness or acquired disease, and not accompanied by other features of autism. The present article concerns all subjects interviewed in the early adult follow-up for whom the basic data described below were available; these comprised 15 with a childhood diagnosis of autism and 17 with a childhood diagnosis of receptive language disorder (RLD). All were male and the mean ages in the two groups were 23.9 and 24.7 years, respectively (Table I).

Assessments carried out as part of the main longitudinal study showed that subjects with autism had a somewhat lower mean verbal IQ than the RLD subjects, and more of them had severe impairment of all aspects of

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Table I. Characteristics of Subject Groups

(I) (II) (III) (IV) RLD Autism Autism Autism Probability a

(all) (high) (low) p (I = II) p (I = III)

n 17 15 10 5

Age (years) Range 21.8-28.2 21.3-26.6 21.2-26.2 22.2-26.6 M 24.7 23.9 23.9 23.8 ns ns SD 1.6 1.7 1.7 1.8

Verbal IQ (WAIS-R) Range 57-88 51-91 59-91 51-61 M 75.35 68.53 75.3 55 < .10 ns SD 7.58 12.59 9.69 3.63

PPVT standard scores b Range 18-87 18-94 32-94 18-43 M 64.47 45 56 23 < .05 ns SD 19.13 24.83 22.61 10

Mean length of utterance (morphemes) Range 2.9-10.6 1-13.4 2.6-13.4 1-2.6 M 5.9 5.4 6.9 2.4 ns ns SD 2.24 3.75 3.68 1.15

No. of utterances in language sample Range 56-203 16-138 37-138 16-79 M 117.3 74.1 86.6 49 ns ns SD 43.3 33.4 31.6 20.0

aSignificance tests are two-tailed t-tests and use log-transformed rates where appropriate (see text).

/'Derived from British Picture Vocabulary Scale scores. Subjects scoring below the floor of this scale were allocated scores 1 point below the floor.

language (Table I). As any differences found between the two groups in the degree or type of pragmatic impairment might have simply reflected differences in basic language skills, the group with autism was subdivided into those with severe impairment in overall language level, and those whose overall language level was comparable with the RLD subjects. This was done using the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 1989) measure of "Overall Level of Non-echoed Language," the 5 subjects in the 2 lowest level categories on this measure being assigned to a separate lower functioning autism group. As shown in Table I, subjects in the higher functioning autism group were closely similar to RLD subjects in verbal IQ, and there was no significant difference between these two


groups in verbal skills as measured by Peabody Picture Vocabulary Test (PPVT) standard scores, nor in mean length of utterance (MLU) in the language samples used in this study.

Collection and Coding of Language Samples

All subjects had been interviewed using the ADOS (Lord et al., 1989) as part of the main longitudinal study, and the raw data used here were conversational samples drawn from these interviews. The instrument con- tains a section in which the interviewer is required to engage the subject in a brief unstructured conversation, guided by standard prompts, which is fol- lowed by a section exploring the subject's use and understanding of concepts concerning emotional states and personal qualities. Both sections were included in the language samples analyzed here as some of the "conversation" sections were brief (mainly in individuals with severe communicative impairment), and the section on socioemotional concepts provided a means of as- sessing the impact of a contextual change on the linguistic features measured. Audiotaped sections of the ADOS interviews were extracted by the original interviewer, and these were transcribed and coded by the author blind to diagnosis and to other information collected in the course of the main follow-up study. Transcripts included prosodic and contextual information where this appeared important in interpreting an utterance.

The transcripts were initially coded using a pilot version of the set of methods developed by Bishop and Adams (1989), which yield frequency counts for a variety of conversational features including aspects of exchange structure, turn-taking, and inappropriate utterances. Most elements of this assessment are of demonstrated reliability. Bishop and Adams cited a correlation of .79 between the rates of inappropriate utterances coded by different observers, and a correlation of .89 for short-term test-retest reliability. The current author achieved a high level of reliability using the training material provided (for rating inappropriate utterances in the exer- cises in the authors' training manual, kappa = .84). It should be noted that Bishop and Adams used a standard conversational task, and the frequency data they obtained cannot be be generalized directly to different linguistic situations; consequently, the frequencies of particular features in the language samples reported here are not directly comparable with those in Bishop and Adams's study. Details of the global pragmatic indices calculated from these initial codings are given in the section "Analyses Using Global Measures of Pragmatic Impairment."

A further coding of the transcripts was carried out in order to relate the occurrence of pragmatic impairments to their conversational context. As

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mentioned earlier, the topics covered in the language samples spanned simple factual matters, and everyday activities and interests, in the conversation section; and less concrete socioemotional topics, especially where subjects' explicit social knowledge and comprehension were being assessed (although topics of this kind also arose in the conversation section). All utterances were coded according to whether the contextual expectation (not the subject's actual response) was an utterance on an "emotion" topic, a "person" topic, or an "other" topic. Person here refers to discussion of individuals' inner qualities or motivations (including responses to questions about friendship and marriage); simple factual discussion about family members, such as where they lived, or what their jobs were, were classified as other. In the analysis no difference was found between emotion and person contexts and they have been aggregated as "socioemotional" contexts.

Measurement of Social Impairment

Social impairment was measured using ADOS ratings which had been made independently in the main longitudinal study (Rutter et al., 1992), namely, those in the ADOS section covering impairments of "Reciprocal social interaction" (see Table II). Most of the 12 items in this section are

Table II. Items in Two ADOS Sections Used as Behavioral Indicators

Reciprocal social interaction

Amount of social overtures Quality of social overtures a Quality of social response Amount of reciprocal social communication a Overall quality of rapport Appropriate greeting/parting Appropriate social distance/posture Social disinhibition Socially unacceptable habits Appropriate eye contact Appropriate smiling

Stereotyped, restricted, and manneristic behavior

Unusual preoccupation with special interests/activities Unusual sensory interest in play material/person Compulsions/rituals Mannerism and stereotyped movements (autistic type) Other mannerisms or stereotyped movements

altems that depend substantially on verbal as well as nonverbal behavior.


nonverbal, the remainder (see Footnote a in Table II) taking account of verbal communication in conjunction with nonverbal behaviors. Each item is coded on a 2- or 3-point scale, impairment or abnormality always producing a higher rating, and the items were aggregated by summing the scale points across all items in the section to give a single Social Impairment score.

A second behavioral variable was derived using material from the ADOS section covering "Stereotyped, restricted and manneristic behavior," once again by aggregating ratings for individual items into a single Stereo- typed Behavior score. The items included in this section are shown in Table II.

Analyses Using Global Measures of Pragmatic Impairment

In the first series of analyses, the pragmatic measures used were derived directly from the codings carried out under Bishop and Adams's scheme. These focused mainly on rates of inappropriate utterances, which Bishop and Adams found to be the best discriminators between subjects with semantic-pragmatic disorder and other language-impaired subjects. The judgment of an utterance as inappropriate depends on an initial global impression of oddness and disruption of normal conversational flow, and Bishop and Adams's overall category includes both instances where the subject produces an utterance that is inappropriate in its context, and instances where the subject fails to produce any utterance, either verbal or nonverbal, in a context where a response of some kind would be expected (an empty turn). As the latter are quite distinctive, the total inappropriacy rate for each subject was supplemented by rates in which these two very broad types of inappropriacy were distinguished:

Total Inappropriacy Rate. The numerator was the count of all inappropriate utterances as defined by Bishop and Adams. The denominator was the total number of utterances, including empty turns, but excluding incomplete or unintelligible utterances and contentless follow-ups and place-holders.

Positive Inappropriacy Rate. A separate index of positively inappropriate utterances was calculated which excluded empty turns from the numerator and denominator.

Empty Turn Rate. Empty turns as a proportion of all speaking turns. Raw values for these three rates are given in the tables, but their

distributions were skewed, and for statistical testing, the rates were transformed logarithmically, using counts started by 0.5.

Initiation Ratio. A further global index was derived from the coding of exchange structure included in Bishop and Adams's assessment: The

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Table III. Group Comparisons on Summary Pragmatic Indices

(I) (II) (Ill) (IV) RLD Autism Autism Autism

(all) (high) (low)

Probability a

p (I = II) p (I = I I I )

n 17 15 10 5

Total inappropriacy Range 0-.21 .01-.73 .01-.44 .39-.73 M .054 .342 .210 .605 SD .056 .236 .150 .137

Positwe inappropriacy Range 0-.12 0-.67 0-.35 0-.67 M .039 .204 .141 .329 SD .036 .192 .118 .244

Empty turns Range 0-.10 0-.66 0-.27 .05-.66 M .017 .162 .076 .332 SD .033 .184 .082 .211

Initiation ratio Range .17-.84 .01-.77 .05-.77 .01-.27 M .527 .279 .364 .108 SD .216 .238 .242 .095

< .001 < .01

< .01 < .05

< .001 < .02

< .01 < .10

aSignificance tests are two-tailed t-tests and use log-transformed rates where appropriate (see text).

number of utterances classified as initiations or continuations was divided by the number classified as responses to interviewer utterances. A low initiation ratio could involve appropriate responses to questions, but would reflect a poverty of spontaneous comments and high reliance on the interviewer to structure the conversation.

Results

Diagnostic Group Differences

Autistic subjects overall were significantly more impaired than RLD subjects on all four global indices. They produced more inappropriate utterances overall, more positive inappropriate utterances, more empty turns, and they displayed lower initiation ratios (Table III). These differences largely remained when comparison was restricted to the higher functioning


autistic subjects. Only for the initiation ratio did the difference between RLD and higher functioning autistic subjects fall slightly short of the two- tailed 5% significance level. If the analysis was confined to utterances produced in nonsocioemotional contexts, the same pattern of findings was produced, although the group differences were smaller.

These results were not unexpected, and demonstrate that the methods developed by Bishop and Adams are useful in detecting and quantifying communicative impairments of the kinds known to occur in autistic subjects. Nonetheless, the distributions of inappropriacy rates in the two diagnostic groups overlapped. Although a normal comparison group was not studied, and there are no normative data for the instrument in the social situation examined here, it appears likely that RLD subjects here produced substantially more inappropriate utterances than would be expected among normal subjects: Even in a relatively demanding situation, the upper limit among normal individuals is probably less than 5% (D. V. M. Bishop, personal communication), whereas the mean among RLD subjects here was 5.4%.

Relationship to Context of Utterance

For each subject, the three global inappropriacy rates were calculated separately (a) among utterances classified as socioemotional in context, and (b) among utterances classified as nonsocioemotional in context. The ratio between these two rates was calculated for each subject) and the mean ratio in each group is shown in Table IV. Thus in RLD subjects, the total inappropriacy rate was on average about twice (1.95) as great in socioemotional as in nonsocioemotional contexts. Table IV shows that the mean ratios for each of the inappropriacy rates was around 2 in all groups. Dif- ferences between the groups were not significant. The ratios tended to be somewhat greater among autistic subjects, and it was only here that the ratios differed significantly from 1. Autistic subjects with lower language functioning tended to show higher ratios than did autistic subjects with higher language functioning (i.e., the effect of context appeared greater among the lower functioning subjects).

Relationship to Measures of Social Behavior

The ADOS Social Impairment scores were treated as ordinal variables and their relationships with the pragmatic indices assessed by rank

3The rates used counts started by 0.5 to avoid zero denominators. This approach is inapplicable to the initiation ratio.

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Table IV. Ratios of Inappropriacy Rates in Socioemotional Versus Nonsocioemotional Contexts

Autistic Autism Autism RLD (all) (high) (low)

n 17 15 10 5

Total inappropriacy M ratio 1.95 2.86 b 2.54/' 3.49 SD 2.22 1.89 1.16 2.72

Positive inappropriaey M ratio 1.77 2.48 b 2.27 a 2.56 a SD 1.99 1.63 1.66 2.91

Empty turns M ratio 1.83 1.95 1.39 3.07 SD 2.63 2.38 1.08 3.58

< .05, two-tailed probability that mean ratio = 1 (t test). P < .02, two-tailed probability that mean ratio 1 (t test).

Table V. Within-Group Rank Correlations (Spearman's r) Between ADOS Impairment of Reciprocal Social Interaction

Score and Global Pragmatic Indices

Autism Autism RLD (all) (high)

n 17 15 10

Total inappropriacy .57 a .84 c .89 b Positive inappropriacy .47 .75 c .920 Empty turns .65 b .52 .33 Initiation ratio - .72 c - .58 a - .56

pp< .05, two-tailed probability that r = 0. < .01, two-tailed probability that r 0.

Cp < .005, two-tailed probability that r = 0.

correlation. Among subjects with autism, higher rates of inappropriacy were associated with greater impairment of social interaction in ADOS, and this applied especially to positive inappropriacy (Table V). These associations were particularly strong among autistic subjects with higher language functioning. Among RLD subjects, there were similar associations, but the features most strongly related to social impairment were empty turns and a low initiation ratio.


Disaggregation of Types of Inappropriate Utterance

As noted earlier, inappropriacy groups together a diverse set of abnormalities, which may have different causes and associations, and clearer findings are likely to emerge if it can be disaggregated into types of inappropriacy that are more homogeneous. Bishop and Adams used a complex subclassification of inappropriacy, some aspects of which were of low reliability. In the present study, a different approach was adopted, in which each inappropriate utterance was classified on two independent dichoto- mous dimensions.

Impairment of Communicative Intention Versus Impairment of Execution

Intentions, and the recognition of others' intentions, are central to the social use of language: The communicative function of an utterance is fulfilled by (or by virtue of) the listener's recognition of the intention the speaker had in producing it (Grice, 1957; Sperber & Wilson, 1986, pp. 54- 64; Strawson, 1964). In this respect communication differs from other types of intentional activity, including behavior aimed at modifying the social environment, that do not depend for their fulfillment on others recognizing the actor's intention. Accurate inference of communicative intentions depends on speaker and listener sharing a cooperative orientation, and more specifically, expectations that communicative intentions are relevant and informative to the listener in the context concerned, and are expressed as clearly and unambiguously as is needed for the listener readily to infer the meaning intended (Grice, 1975, 1978).

The first dichotomy therefore contrasted the following: Impairment of Communicative Intention. Utterances that were inap-

propriate because a relevant communicative intentiorl was lacking. Impairment of Execution. Utterances that contained (or appeared to

contain) a relevant communicative intention, but where the way in which this was expressed was inappropriate, that is, there was a lower level failure in the execution of a relevant intention.

For the present purpose, the communicative intention of an utterance can be taken as roughly equivalent to its intended meaning in the context concerned. Relevant here does not simply mean that an intended meaning is on topic, but that in the context in which an utterance is produced, it is appropriately informative to the listener, or in Sperber and Wilson's terms that it has a significant contextual effect on the listener's assumptions (see Sperber and Wilson, 1986, pp. 118-125 & passim). Although relevance

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is a matter of degree, this did not need to be evaluated to make the present distinction: What was required was a judgment of whether the inappropriacy of an utterance arose because of the lack of an intention relevant to the context in which the utterance occurred, or because the precise intention was difficult to infer or there was some other unusual feature in the way it was expressed. These are essentially different ways in which Grice's (1975) "cooperative principle" can be breached. 4 Examples of utterances falling into the two categories are given in the Appendix.

Presence or Absence of Stereotyped Language

A well-recognized feature of the speech of some individuals with autism is the stereotyped and relatively context-insensitive use of literally repeated words or phrases. This has been termed "formulaic" language by some authors (e.g., Tager-Flusberg, 1989) and is represented in the Lan- guage section of the ADOS interview by the category "Stereotyped phrases." Language of this type often creates an unusual impression and provides a possibly distinctive source of inappropriacy. Its presence or absence cuts across the dichotomy between impairment at the level of intention or execution: It may appear, for example, in irrelevant stereotyped utterances, or in an unusual "officialese" quality to an utterance conveying relevant information.

Stereotyped language was rated where a word or phrase appearing in the utterance in question was used by the speaker in an inappropriate repetitive manner within the language sample analyzed, or where there was a clear suggestion of stereotyped repetition from another source (e.g., echolalia, advertising jingles inappropriately introduced into the conversation, officialese language). This rating was conservative, and it is likely that some instances of stereotyped word use or phraseology were coded as nonstereotyped because positive evidence that the usage was stereotyped was lacking.

4It would be useful to add to the components of Grice's (1975) maxim of Manner (avoid obscurity of expression, avoid ambiguity, be brief, be orderly) a fifth, "avoid quirky or deviant usage," on the grounds that such usage hinders the listener in readily inferring the meaning intended (although as with the other maxims it can be deliberately flouted in normal conversation for particular communicative purposes). With this condition the category "impairment of execution" used in the present analysis corresponds to utterances that breach Grice's maxim of Manner, and the category "impairment of communicative intention" to utterances that breach his maxims of Quantity, Quality, and Relevance. The distinction made here is congruent with a difference among Grice's maxims in that conversational implicatures dependent on the maxim of Manner are specifically linked to the linguistic form of the utterance, whereas those dependent on the other maxims are not (Griee, 1975, pp. 55 ft.; Levinson, 1983, pp. 116-117).


Reliability

A second rater (blind to diagnosis) classified 86% (49/57) of a sub- sample of inappropriate utterances in the same way as the original rater in terms of the dichotomy between impairment of communicative intention versus impairment of execution (kappa = .69), and 86% (49/57) in the same way in terms of the distinction between presence or absence of stereotyped language (kappa = .61). Although adequate for the present purpose, these levels of reliability were achieved following quite limited training and could no doubt be improved.

Results

Diagnostic Group Differences

Rates for subtypes of inappropriacy based on these distinctions were calculated, and group comparisons are shown in Table VI. Inappropriate utterances involving stereotyped language use, and those involving impair-

Table VI. Rates of Subtypes of Inappropriacy

(II) (III) (IV) Probability a (I) Autism Autism Autism

RED (all) (high) (low) p (I = l l ) p ( I = III)

n 17 15 10 5

Impairment of communicative intention Range 0-.093 0-.67 0- .30 0- .67 M .017 .172 .104 .307 < .005 < .025 SD .023 ,188 ,104 .238

Impairment of execution Range 0-.09 0-.11 0-.11 0-,06 M .022 .032 .037 .022 ns ns SD .022 .032 .033 .027

Impairment of execution (nonstereotyped only) Range 0-.09 0-.08 0-.08 0- .02 M .021 .018 .023 .009 ns ns SD .022 .021 .024 .011

Stereotyped language Range 0--. 116 0- .67 0-. 14 0-.67 M .008 .094 .033 .216 < .001 < .01 SD .028 .166 .047 .237

aSignificance tests are two-tailed t tests and use log-transformed rates where appropriate (see text).

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Table VII. Ratios of Inappropriacy Subtype Rates in Socioemotional Versus Nonsocioemotional Contexts

Autism Autism Autism RLD (all) (high) (low)

n 17 15 10 5

Impairment of communicative intention M ratio 1.94 2,66 ~ 1.80 4.38 SD 2.02 2.82 1.63 3.75

Impairment of execution (nonstereotyped only) M ratio 1.17 1.20 0.82 1.97 SD 1.41 1.09 0.78 1.21

Stereotyped language M ratio 0.92 2.02 2.06 1.93 SD 0.69 3.54 4.18 1.67

ap < .05, two-tailed probability that mean ratio = 1 (t test).

ment of communicative intention, were both much more frequent among subjects with autism. However, inappropriate utterances involving impairment of execution showed much less disparity between the groups, and in particular nonstereotyped impairment of execution (which made up 22% of all instances of inappropriacy in the sample as a whole) occurred as frequently in RLD subjects as in those with autism. This provides partial vali- dation for the classification of inappropriate utterances used here.

Relationship to Context of Utterance

The relationship between these subtypes of inappropriacy and language context was examined in the same way as in the earlier analysis using the global pragmatic indices. Inappropriacy involving impairment of communicative intention showed ratios roughly the same as those of the global indices, that is, utterances of this type were about twice as frequent in socioemotional contexts (Table VII). Among autistic subjects, stereotyped language showed a similar pattern. In contrast, in all groups (with the possible exception of lower functioning autistic subjects), inappropriacy involving nonstereotyped impairment of execution was unrelated to context, with ratios close to 1.


Relationship to Measures of Behavior

Inappropriacy involving impairment of communicative intention, like the global pragmatic indices, was closely associated with greater impairment of social interaction in ADOS (Table VIII). Here also the associations were particularly strong among autistic subjects with higher language functioning. In all groups, social impairment was also associated with the use of stereotyped language. In contrast, nonstereotyped executive pragmatic impairment was unrelated to degree of social impairment.

Scores for Stereotyped Behavior derived from ADOS ratings were unrelated to the measures of stereotyped language used in the present study (in the higher functioning autistic group, Spearman's correlations between the ADOS score and stereotyped language rates excluding and including echolalia were .03 and .036, respectively). This indicates that stereotyped language use, as defined here, is not closely related to the other forms of repetitive behavior considered in this ADOS section.

DISCUSSION

This study was based on a relatively small number of subjects, and although part of a long-term longitudinal study, the language samples used were collected at a single (late) developmental stage. Some of the language samples were relatively short. Although the RLD group was well matched with the higher language-functioning autistic group on verbal IQ, PPVT, and mean utterance length, each of the diagnostic groups was quite heterogeneous in terms of verbal skills and general intelligence, and no group of normal speakers was available for comparison. All of these items point

Table VIII, Within-Group Rank Correlations (Spearman's r) Between ADOS Impairment of Reciprocal Social Interaction Score and Subtypes of Pragmatic Impairment

Autism Autism RLD (all) (high)

Impairment of communicative intention Impairment of execution (nonstereotyped only) Stereotyped language

17 15 10

.58 a .67 a .863

.07 .16 .38

.59 a .55 a .59

< .05, two-tailed probability that r = 0. pP< .01, two-tailed probability that r 0.

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to a need for caution in interpreting the results, and for confirmation of the findings in further studies. However, the methods used appear to have captured some important characteristics of the individuals studied, and it is worthwhile to consider some implications of these results.

Different Types of Pragmatic Impairment

Inappropriate utterances arising from failures in the execution of communicative intentions were equally frequent in the two diagnostic groups, were as frequent in simple conversational situations as in the more demanding contexts where socioemotional topics were discussed, and were unrelated to independent measures of social impairment drawn from the ADOS interview. In each of these respects they differed from inappropriate utterances arising from failure to form a relevant communicative intention. The only qualification needed is that stereotyped language, whether or not it was used in conveying context-appropriate intentions, was associated both with a diagnosis of autism and (within each diagnostic group) with greater social impairment. The internal consistency between these findings provides strong evidence that pragmatic impairments involving failure of execution and those involving failure of intention arise from different functional bases, and should be treated separately in studies into their occurrence---although neither category is necessarily homogenous, and further distinctions may be required in future research. While impairment of execution can clearly be dissociated from social impairment more generally, impairment of intention apparently cannot, at least in the groups studied here.

Although the two classes of impairment could be distinguished with reasonable reliability here, one caveat should be made. Making the distinction requires that the speaker's intended meaning be inferred accurately, at least within certain broad limits, a judgment that may be complicated by executive impairment itself: Severely disturbed execution may, for example, render a speaker's intention completely obscure. In the present study, problems of assessment were limited by the fact that abnormal or irrelevant intentions were often expressed with great clarity, and executive impairments were sufficiently mild to enable the underlying intentions to be recognized within useful limits. This may not be so in some other contexts (e.g., "formal thought disorder" in adult psychoses).

It is important that the distinction made here is interpreted correctly. It hinges on a notion of relevant communicative intention based on the work of Grice, taking up both the concept of communicative intention he develops (Grice, 1957; see also Levinson, 1983, pp. 16-17, 100 ft.; Schiffer, 1972; Sperber & Wilson, 1986; Strawson, 1964) and his notion that par-


ticipants in a conversation must adhere to a principle of cooperation and hold mutual expectations of relevance and clarity if their communicative intentions are to be reliably inferred (Grice, 1975, 1978; Sperber & Wilson, 1986). This concept of communication concerns a highly specific type of intentional activity, and should not be confused with "communicative intent" defined simply in terms of the intention to have an effect of some kind on other people (Prizant & Wetherby, 1987; see also Prizant & Dun- chan, 1981; Wetherby, 1986). The latter does not distinguish meaningful communication form other types of intentional activity, and would include attempts to influence others by "natural" means (in the sense discussed by Grice and, e.g., by Levinson, 1983, pp. 16-17), for example, by exploiting observed regularities in their behavior. 5

Pragmatic Impairments in Individuals with Autism

Inappropriacy arising from impairment of intention was much more common in subjects with autism than in subjects with RLD, and this ac- counted for most of the difference between the two groups in overall inappropriacy rates. Bishop and Adams (1989) hinted at a similar finding in their study of children with "semantic-pragmatic disorder," where those who produced inappropriate utterances in which "the abnormality was not in how the message was conveyed, but in the message itself" tended to have other features suggestive of autism or a related condition. The finding is also consistent with Tager-Flusberg's (1989) conclusion that pragmatic deficits in autism characteristically arise from impairment in the formulation of appropriate communicative intentions.

It is important to distinguish these comments from the proposal that autistic individuals have normal or unremarkable "communicative intentions" but attempt to convey these by "unconventional means" (Prizant & Wetherby, 1987). As noted earlier, the concept of communicative intention used here differs from that of Prizant and Wetherby, and the distinction between "intention" and "execution" does not correspond to the distinction these authors make between "intents or purposes for communicating" and "the means...use[d] to express those intents" (Prizant & Wetherby, 1987, p. 473). The specific communicative intentions dealt with in the present study could be seen as particular ways in which more general social motivations or "purposes" are "expressed," and although the present results do not support Prizant and Wetherby's proposal, they are not necessarily in-

SWetherby (1986) partly acknowledged the specific character of communication (as the word is used here) in distinguishing between social and nonsocial "ends" of intentional activity, but her discussion is couched in terms of the content of an intention, not its reflexive form.

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consistent with it. It appears that differences in the use of the word com-

municat ion underlie, at least in part, conflicts of view between those who have emphasized the communicative or the noncommunicative nature of language in autism.

A close relationship was found between impairment of communicative intention and impairment of reciprocal social behavior more generally; the ADOS ratings from which the social impairment index was derived were made independently of the pragmatic assessment, and as the index de- pended largely on nonverbal behavior there is limited scope for simple con- tamination in measurement. This finding broadly supports the assimilation of pragmatic abnormalities in autism to social-cognitive impairment (Baron- Cohen, 1988; Goodman, 1989; Loveland & Tunali, 1991; Tager-Flusberg, 1989), although a number of qualifications need to be made.

First, impaired execution of communicative intentions occurred as frequently in subjects with autism as it did in those with RLD. As noted earlier, its frequency was probably elevated in both of the groups studied here relative to normal speakers, although in the absence of a normal comparison group this conclusion must be tentative. This suggests that a proportion of context-inappropriate utterances in autism (on average 16% among individuals in the present series) arise not through social-cognitive impairment but through other mechanisms. These would include mechanisms relatively specific to autism, such as those underlying the use of unusual speech styles, neologisms, or stereotyped language to convey appropriate communicative intentions (cf. Volden & Lord, 1991); but probably also mechanisms shared with RLD subjects, such as problems in sentence formulation, suggesting that more language-specific deficiencies remain relevant in autism (cf. Goodman, 1989).

Second, although impairment of intention was much more frequent among autistic than among RLD subjects, many utterances in individuals with autism were nonetheless coded here as containing a relevant communicative intention (range, 33-100%; M, 83%). This recalls the finding of a study of the same subject group in childhood, where despite a high frequency of abnormal speech, 68% of utterances were rated as "communicative or socialized" (Baker, Cantwell, Rutter, & Bartak, 1976). This apparent inconsistency in individuals' performance poses a problem for theories that attribute pragmatic impairments to a static deficit in social- cognitive competence, and may reflect a methodological or a more sub- stantive issue.

The methodological issue is that some utterances may have been incorrectly assessed as containing a relevant communicative intention. They may have reproduced the surface form of a communicative act without ac- tually arising from the type of intention here attributed to them. For ex-


ample, a speaker might respond simply by applying a fixed rule which most of the time, but not always, is effective in producing a conversationally appropriate utterance (some of the conversation of normal speakers probably consists of automatic or routinized responses of this type, although pre- sumably these can be expanded appropriately whenever the situation de- mands it). Overattribution of communicative intention is quite possible in the present study: As in normal conversation, every utterance was initially assumed to contain a relevant communicative intention, and this assump- tion was abandoned only if no such intention could reasonably be attributed. Nonetheless, some autistic subjects produced complex appropriate utterances displaying a clear grasp of listener needs and it does not appear likely that all instances of appropriate communicative intention in autistic subjects were attributed incorrectly.

This suggests that individuals who had the capacity to formulate relevant communicative intentions were not always able or motivated to employ it in the course of their conversation. One possible reason for this is variable comprehension: The increased frequency of impairment of intention in socioemotional contexts, where autistic individuals would be expected to have greater comprehension difficulties, suggests that this explanation ac- counts for a least a proportion of instances. Another might be fluctuation in the orientation of the speaker's attention toward the current social context, including the listener's concerns and needs, rather than toward other material, resulting from variable pressure of stereotyped preoccupations, or from fragile social attention that is vulnerable to intermittent disruption (i.e., a specific type of distractibility). The data collected in the present study indicate the need to examine more specifically the phenomenon of inconsistent performance, and factors that could explain it.

Pragmatic Impairments in Subjects with RLD

Inappropriate utterances involving impairment of execution made up just over half of the instances of inappropriacy in RLD subjects. Pragmatic lapses of this type are widespread as occasional phenomena in the speech of normal individuals, and are known to occur more frequently where functions such as attention or speech planning are disturbed (e.g., in acute schizophrenia; Rochester, Martin, & Thurston, 1977).

Compared with autistic subjects, those with receptive language disorders had much lower rates of inappropriacy involving impairment o f intention, although the groups overlapped, implying that some RLD subjects did have significant difficulty in forming context-relevant intentions. Given that major difficulties in language comprehension almost inevitably lead to

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problems in communicating in a manner appropriate to the linguistic context, it may seem surprising that the overlap is not greater. That it is not largely reflects the fact that major comprehension difficulties were not evi- dent at a conversational level in most of the RLD subjects studied here in adult life. Earlier in development, more pronounced comprehension difficulties in members of this group might have produced greater similarity to the autistic subjects.

In the group with RLD, as in those with autism, social impairment as measured by ADOS was closely related to failure of intention, as well as to the rate of empty turns and to a low initiation ratio. A relative lack of social initiative (reduced rates of initiating social interaction, greater de- pendence on others to structure interaction), not restricted to verbal interaction, has been described in studies of developmental language disorders in childhood (Cunningham, Siegel, Van der Spuy, & Bow, 1985; Siegel, Cunningham, & Van der Spuy, 1985), and children with language delay in early childhood were found to be more "introverted" than their peers at the age of 7 by Kolvin, Fundudis, George, Wrate, & Scarth (1979). The features shown here by adult RLD subjects with social impairments may reflect a similar phenomenon in more extreme form.

APPENDIX

Rating of Impairment of Communicative Intention Versus Impairment of Execution

Impairment of Relevant Communicative Intention

Includes: (a) utterances involving the positive presence of an irrelevant intention, for example, inappropriate persistence of or reversion to a previous topic (including ignoring initiations by the other party); furnishing irrelevant on-topic information, such as excessive detail clearly inappropriate to its context; inappropriate shift to a new topic; (b) utterances that are inappropriately uninformative. (@ Indicates an utterance coded inappropriate.) Examples:

(1)

S: Peter Adams and James Wright -

E: mmhmm/

S: Make Philip angry/

E: What do they do?/

Pragmatic Impairments in Adults with Childhood Diagnoses of Autism or RLD

S: Don't like Mrs Coster/@

[Ignores E question and continues to list people who make him angry.] (2)

E: Catherine is y o u r - - ? /

S: Sister/

E: Sister/

Right/

Is she younger than you or older than you?/

Catherine Smith/@ S:

613

[Gives further on-topic information that does not address E question.] (3)

E:

S

And what happens in the book?/

The fireman is called to an emergency when he slides down the pole and puts his uniform on and drives the fire engine off to a fire/

E: mmhmm/

And why did you like that book?/

S: Well---wh ̂ when there's a fire in the building there's an emergency call/@

[Fails to address E question, instead providing more factual details about the content of the book.]

(4)

E: Is there anything else you can tell me about [Prince Andrew]?/

S: At the age of eight and a half he attended Aberdare school and then in 1973 at the age of 13 he attended Gordonstoun/@

[Despite addressing the general topic of the question, provides excessive detail inappropriate to the context.]

(5)

E: Is Jane married?/

S: No/

E: mmhmm/

She's got a friend and she lives in America?/

S: Museums all shut now/@

(6)

E: How do you feel when you're frightened?/

S: Fishes in the sea/@

(7) E: What sort of person is [your sister Sally]?/

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S: She is she is a girl/@

[In this context the fact that Sally is a girl was implied as mutually known, hence utterance uninformative.]

(8)

E: Where do mummy daddy live?/

S: Mummy and daddy live@/

Impairment of Execution

Includes all utterances coded "inappropriate" in which there appears to be a relevant informative intention. These include utterances that are ver- bally muddled or vague (where the precise intended meaning is difficult to infer); utterances in which pronouns or definite articles have unclear intended referents; and utterances producing a disruptive impression through an unusual choice of wording. (@ Indicates an utterance coded inappropriate.) Examples:

(9)

E: What's different about ]sadness and anger]?/

S: Feeling more a n g " anger when things don't go away for me/@

[Utterance appears to make a comparative statement which would be appropriate in context, although the actual comparison made is difficult to make out.]

(10) S:

E:

S:

[Unclear

(11)

E:

S:

She does er she does a job as secretary/ But I think she moves around for the jobs because of the speed/ I think they do like six so many words a minute/

Right/

I think they do it somewhere else/@

referent of "it."]

Can you describe how it feels when you're feeling happy?/

---um--I would say that it gives me a better background about er thinking about more ideas in life/@

[Although appearing to address the question appropriately and to identify a possibly relevant feature of "feeling happy" the response is vague and the precise meaning is unclear.]

(12)

E: What have you seen recently on TV that you've enjoyed?/

Pragmatic

S:

E:

S:

E:

S:

E:

S:

Impairments in Adults with Childhood Diagnoses of Autism or RLD

ura--Sweeney Two/

Sweeney Two?/

Yeah/

Can you tell me a bit about that?/

It's about a bank robber/

mmhmm/ mmhmm/

And they're out to get them/@

615

[Al though the re ferents to " they" and " t h e m " can be guessed, they are

unc l ea r and are no t i n t roduced appropriately.]

(13)

E:

S:

[Oddi ty

(14)

E:

S:

. . Anything else you can tell me? [about what you do with friends]/

(11 secs) er that joining the sports we like/@

of expression appear ing to convey an appropr ia te meaning . ]

How is [your mother] different from other people?/

She's slightly tall/@

[Refer r ing to a physical character is t ic is no t inappropr ia te to the context ,

bu t "slightly tall" is an u n u s u a l expression.]

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