SOCIAL COMMUNICATION

DEVELOPMENT AND DISORDERS

This new standout volume is the first to describe developmental areas

associated with social competence and social communication, as well as
provide evidence-based information on effective assessment and inter-
vention for children who have problems with social communication
and social interactions. Expertly crafted, the volume offers both theory
and practice within one comprehensive, yet manageable resource for
busy professionals. The first section covers social communication the-
ory and associated developmental domains. Case studies are provided
to exemplify how different variables may affect social communication
development. The second section covers evidence-based practices for
social communication disorders and includes case studies, incidence
and prevalence estimates, the current DSM-5 definition of the disorder,
referral guidelines, recommended practices of assessment and interven-
tion, and a list of clinical resources.
Social Communication Development and Disorders is an ideal text
for a range of courses in Communication Sciences and Disorders or
Speech-Language Pathology, and a must-have reference for profession-
als working with children with social competence or social communica-
tion problems, including speech-language pathologists (SLPs), regular
and special educators, psychologists, and support personnel such as
social workers, counselors, and occupational therapists.

Deborah A. Hwa-Froelich, PhD, Professor at Saint Louis University,

conducts research on sociocultural, socioeconomic, and social-emotional
factors influencing communication development and disorders. She
has received several awards, including Fellow of the American Speech-
Language-Hearing Association and the Angel in Adoption award from
the Congressional Coalition for Adoption Institute.
 LANGUAGE AND SPEECH DISORDERS
BOOK SERIES
Series Editors
Martin J. Ball, Linköping University, Sweden
Jack S. Damico, University of Louisiana at Lafayette

This new series brings together course material and new research for
students, practitioners, and researchers in the various areas of language
and speech disorders. Textbooks covering the basics of the discipline
will be designed for courses within communication disorders programs
in the English-speaking world, and monographs and edited collections
will present cutting-edge research from leading scholars in the field.

PUBLISHED
Recovery from Stuttering, Howell
Handbook of Vowels and Vowel Disorders, Ball & Gibbon (Eds.)
Handbook of Qualitative Research in Communication Disorders, Ball,
Müller & Nelson (Eds.)
Dialogue and Dementia, Schrauf & Müller (Eds.)
Understanding Individual Differences in Language Development Across
the School Years, Tomblin and Nippold (Eds.)
Unusual Productions in Phonology: Universals and Language-Specific
Considerations, Yavaş (Ed.)
Social Communication Development and Disorders, Hwa-Froelich (Ed.)

For continually updated information about published and forthcom-

ing titles in the Language and Speech Disorders book series, please visit
www.psypress.com/language-and-speech-disorders
SOCIAL COMMUNICATION
DEVELOPMENT AND
DISORDERS

Edited by
Deborah A. Hwa-Froelich
First published 2015
by Psychology Press
711 Third Avenue, New York, NY 10017

and by Psychology Press
27 Church Road, Hove, East Sussex BN3 2FA

Psychology Press is an imprint of the Taylor & Francis Group, an informa business

© 2015 Taylor & Francis

The right of the editor to be identified as the author of the editorial material, and of the authors for
their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright,
Designs and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form
or by any electronic, mechanical, or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or retrieval system, without permission
in writing from the publishers.

Trademark notice: Product or corporate names may be trademarks or registered trademarks, and
are used only for identification and explanation without intent to infringe.

Library of Congress Cataloging in Publication Data

Social communication development and disorders / edited by Deborah A. Hwa-Froelich.
pages cm — (Language and Speech Disorders)
Includes bibliographical references and index.
1. Children with social disabilities. 2. Child development. 3. Child psychology.
I. Hwa-Froelich, Deborah A., editor.
HV713.S617 2014
362.7—dc23
2014026524

ISBN: 978-1-84872-534-8 (hbk)

ISBN: 978-1-84872-535-5 (pbk)
ISBN: 978-1-315-73562-7 (ebk)

Typeset in Minion
by Apex CoVantage, LLC
For my children and grandchildren who taught me much about
social-emotional and social communication development.
This page intentionally left blank
 CONTENTS

Contributors ix
Figures xii
Tables xiii
Acknowledgments xiv

SECTION I
Social Communication Theory
and Associated Developmental Domains 1

Chapter 1 Social Communication Theoretical Foundations

and Introduction   3
DEBORAH A. HWAFROELICH

Chapter 2 Social Neuroscience 20

CAROL E. WESTBY

Chapter 3 Social-Emotional Development Associated

With Social Communication   50
DEBORAH A. HWAFROELICH

Chapter 4 Development of Cognitive Processes Associated

With Social Communication  79
DEBORAH A. HWAFROELICH
viii • Contents

Chapter 5 Social Communication Development   108

DEBORAH A. HWAFROELICH

SECTION II
Evidence-Based Practice for Social Communication Disorders   139

Chapter 6 Assessment and Intervention for Children

With Pragmatic Language Impairment  141
CATHERINE ADAMS

Chapter 7 Social Communication Assessment and

Intervention for Children on the Autism
Spectrum   171
DANAI K. FANNIN AND LINDA R. WATSON

Chaper 8 Social Communication Assessment and

Intervention for Children With Language
Impairment  220
MARTIN FUJIKI AND BONNIE BRINTON

Chapter 9 Social Communication Assessment and

Intervention for Children With Attention
Problems   252
GERALYN R. TIMLER AND KATHERINE E. WHITE

Chapter 10 Social Communication Assessment and

Intervention for Children Exposed to
Maltreatment   287
DEBORAH A. HWAFROELICH

Chapter 11 Social Communication Assessment and

Intervention for Children With Disruptive
Behavior Problems   320
CAROL E. WESTBY

Index   351
 CONTRIBUTORS

Catherine Adams, PhD, is a clinical senior lecturer in Speech and

Language Therapy at the University of Manchester in the UK. She has
previously worked in health care and schools services with a range of
children who have communication needs. Dr. Adams’s research inter-
ests lie in understanding pragmatic language impairments and com-
prehension difficulties in children and obtaining evidence to support
interventions. She is still a practicing speech and language pathologist.

Bonnie Brinton, PhD, is a professor of Communication Disorders at

Brigham Young University (BYU), Provo, Utah. Her work focuses on
assessment and intervention with children who experience difficulty with
social communication. Dr. Brinton has been a professor at the University
of Nevada; a research scientist at the Schiefelbusch Institute for Lifespan
Studies, University of Kansas; and Dean of Graduate Studies at BYU. She
is a fellow of the American Speech-Language-Hearing Association.

Danai K. Fannin, PhD, is an assistant professor of Communicative Dis-

orders at Northern Illinois University. She received her PhD from the
University of North Carolina at Chapel Hill and was a postdoctoral fel-
low in the lab of Connie Kasari, PhD, at the Neuropsychiatric Institute at
University of California, Los Angeles. Her research interests include the
development of evidence-based autism treatment, with a focus on pro-
viding appropriate evaluation and intervention for culturally and lin-
guistically diverse families.
x • Contributors

Martin Fujiki, PhD, is a professor of Communication Disorders at

Brigham Young University (BYU), Provo, Utah. He has authored
numerous publications in the area of social and emotional competence
in children with language impairment. Dr. Fujiki has been a professor
at the University of Nevada and BYU, and a research scientist at the
Schiefelbusch Institute for Lifespan Studies, University of Kansas. He is
currently serving as an associate editor for Language Speech and Hearing
Services in Schools. He is a fellow of the American Speech-Language-
Hearing Association.

Deborah A. Hwa-Froelich, PhD, is professor in the department of

Communication Sciences and Disorders at Saint Louis University. Her
research focuses on sociocultural, socioeconomic, and social-emotional
factors influencing communication development and disorders. She
is the Founder of and a consultant for the International Adoption Clinic
at Saint Louis University. Some of the awards she has received for her
work include Louis M. Di Carlo Award, Diversity Champion, and Fel-
low of the American Speech-Language-Hearing Association. She also
received the Angel in Adoption award from the Congressional Coalition
for Adoption Institute for her work with children adopted from abroad.

Geralyn R. Timler, PhD, is an assistant professor and Director of the

Child Language and Social Communication Lab in the Department of
Speech Pathology and Audiology at Miami University. Her clinical and
research interests focus on social communication and pragmatic skills in
preschoolers and school-age children with Fetal Alcohol Spectrum Dis-
orders, Specific Language Impairment, Attention Deficit Hyperactivity
Disorder (ADHD), and Autism Spectrum Disorders. She has developed
a hypothetical peer conflict task to examine children’s knowledge about
goals and strategies for resolving conflicts with peers. She has also exam-
ined the accuracy of parent report measures, norm-referenced language
tests, and conversational language samples to identify language impair-
ment and pragmatic deficits in children with ADHD. Her work has
been funded by the American Speech, Language, and Hearing Founda-
tion. Dr. Timler is currently serving on the coordinating committee for
the American Speech-Language-Hearing Association’s Special Interest
Group 1, “Language, Learning, and Education.”

Linda R. Watson, EdD, CCC-SLP, is a professor in the Division of

Speech & Hearing Sciences at UNC–Chapel Hill. She has extensive clini-
cal and research expertise in development of and interventions for young
children with ASD. She currently engages in interdisciplinary autism
 Contributors • xi

research, graduate teaching related to autism and other aspects of trans-

lational research, and extensive mentoring of undergraduate and gradu-
ate students with interests in autism research. Ongoing collaborative
research includes efficacy studies of a parent-mediated intervention for
infants at risk for autism and a classroom-based social-communication
intervention for preschoolers with ASD, a longitudinal study of prelin-
guistic predictors of later language outcomes in children with ASD, and
a study of sensory processing patterns of children with autism or other
developmental disabilities.

Carol E. Westby, PhD, CCC-SLP, has received the Honors of ASHA,

Fellow, and the Certificate of Recognition for Special Contributions to
Multicultural Affairs awards. She has published extensively and presents
nationally and internationally on a variety of topics related to child lan-
guage, literacy, and social-emotional development. She is currently a
consultant/supervisor for Bilingual Multicultural Services where she is
piloting a program to promote social-emotional development in pre-
school/elementary school children.

Katherine E. White, BS, will be completing her Master’s degree in

speech-language pathology at Miami University in Oxford, Ohio. Her
contribution to this book includes excerpts from her undergraduate
senior honor’s thesis, titled “Fetal Alcohol Spectrum Disorder (FASD):
What Clinicians Need to Know.” This undergraduate project was sup-
ported by a Dean’s Scholar Award from Miami University’s College of
Arts and Sciences.
 FIGURES

2.1 Dimensions of Theory of Mind 24

2.2 Brain areas involved with Theory of Mind 28
2.3 Effects of genotype–environment interactions on
social skills and ToM 39
11.1 Dynamic Tricky Mix of Individual and Environmental
Treatment Factors 333
 TABLES

2.1 Interpersonal and Intrapersonal Theory of Mind 32

2.2 Examples of Cold and Hot EF Tasks 36
3.1 Development of Emotions 59
3.2 Developmental Changes in Self-Regulation 64
3.3 Independent and Interdependent Views and Goals 71
4.1 Stages of Theory of Mind Development 85
5.1 Nonverbal and Pragmatic Language Development 116
5.2 Operations of Reference and Semantic Relations 118
5.3 Early Prelinguistic Communication of Intention 120
6.1 Assessment Summary for Lucas at the Pre-Intervention Stage 156
6.2 Principles of Intervention in SCIP Intervention 159
6.3 Content of the Individualized Phase of SCIP Intervention
for Lucas 161
7.1 Evidence-Based ASD Screeners 180
7.2 Highly Recommended Guidelines for ASD Assessment Tools 183
9.1 Examples of Empirically Tested Interventions for
Children with FASD and ADHD 271
10.1 Possible Signs of Child Abuse and Neglect 300
10.2 Measures of Social Communication in Children Exposed
to Maltreatment 302
 ACKNOWLEDGMENTS

Several individuals made significant contributions to this book. I would

especially like to thank the contributing authors, without whom this
book would not have been possible: Catherine Adams, Bonnie Brin-
ton, Danai Fannin, Martin Fujiki, Geralyn Timler, Linda Watson, Carol
Westby, and Katherine E. White. I  have had the pleasure of working
with many graduate students who also helped with literature searches
and with reviewing and editing the book chapters: Mary Clare Becker,
Lindsey Boville, Kelsey Rosenquist, and Rebecca Odegard.
 Section I
SOCIAL COMMUNICATION THEORY AND
ASSOCIATED DEVELOPMENTAL DOMAINS
This page intentionally left blank
 1
SOCIAL COMMUNICATION THEORETICAL
FOUNDATIONS AND INTRODUCTION
Deborah A. Hwa-Froelich

These children [children with pragmatic disorder] spoke aloud to no

one in particular, displayed inadequate conversational skills, exhibited
poor maintenance of topic and verbosity and answered besides the point
of a question in the presence of unimpaired phonology and syntax.
—Cummings (2009, p. 47)

LEARNING OBJECTIVES
Readers will be able to
1. Define social competence, pragmatic language, and social com-
munication disorder.
2. Describe the heterogeneity of social communication disorders.
3. Discuss theories related to social communication.
Oliver was initially seen at a Child Find screening at the age of
3.5  years. He was the firstborn son of a two-parent Caucasian fam-
ily from a working-class background that included a younger sister
who was 15 months old. Although Oliver passed the hearing, motor,
and cognitive sections of the screener, he demonstrated difficulty
answering questions and retelling a story. His parents reported that
he had difficulty playing with his cousins and neighborhood children
because he interrupted their play, interrupted their conversations, and

3
4 • Hwa-Froelich

talked nonstop about topics unrelated to what everyone else had been
talking about.
During a more thorough evaluation, Oliver demonstrated low aver-
age receptive and expressive language skills. In particular, Oliver often
answered wh-questions inappropriately, including questions asking
who, what, where, when, or why. His language sample consisted of
several utterances covering a variety of unrelated topics. When asked
to retell a story, he included few details about the original story and
added extraneous information. He was observed to interrupt the
examiner and often expressed off-topic comments. Oliver demon-
strated appropriate functional and symbolic play, but his symbolic
play appeared to involve fewer objects and linked steps as well as fewer
instances of goal-directed play. For example, he often loaded blocks
and miniature animals into a truck, drove the truck to another loca-
tion, and dumped the animals and blocks without a goal as to where
the animals were going or what the blocks were to be used for at the
new location.
Oliver demonstrated a pragmatic language impairment that was
associated with a mild receptive and expressive language impairment.
These weaknesses were also reflected in his symbolic play development.
The early childhood team recommended that Oliver enroll into a special
education preschool program to improve his receptive and expressive
language, play skills, and social communication.
Oliver’s profile of behaviors and development provides an example
of how pragmatic language impairment can affect one’s social and com-
municative competence across contexts and interactions. Although Oli-
ver’s language performance and play development were in the average
range, he exhibited specific weaknesses that were related to social com-
munication skills necessary for interactions and appropriate pragmatic
language. It is difficult to know which developmental weakness—play
or language delays—occurred first or whether these relationships are
causal in nature. Yet, it is clear that Oliver was not able to interact with
others successfully and needed assistance to become more socially com-
petent. The purpose of this book is to describe developmental areas
associated with social competence and social communication, and to
provide evidence-based information to guide professionals working
with children who have problems with social competence or social
communication. This chapter includes (a) definitions of social compe-
tence, social communication, and pragmatic language; (b) descriptions
of theories associated with these skills; and (c) an outline of the chapters
for this book.
 Theoretical Foundations and Introduction • 5

DEFINITIONS AND SIGNIFICANCE

What do I mean by social competence? Simply put, social competence
consists of having the knowledge, skills, and behaviors to fulfill one’s
needs and meet his or her expectations in social interactions (Gold-
stein, Kaczmarek, & English, 2002). Social communicative competence
includes the knowledge and appropriate use of social behaviors, compe-
tent communication, and pragmatic rules. Thus, persons with a social
communication disorder have difficulty with social communication
nonverbal and verbal behaviors and pragmatics. Oliver’s unsuccessful
interactions with peers and adults reveal his poorly developed social
competence. He also struggled with social communication when he did
not understand or effectively use communication in socially expected
ways, such as answering questions, maintaining topics, taking turns in
conversation, making accurate inferences from nonverbal behaviors or
ambiguous language and repairing his communication when others did
not understand him. All social interactions are contextually based and
dynamic in that when involved in social interaction, individuals simul-
taneously access and process their knowledge and experiences with oth-
ers and the world. Knowledge about people and the world is acquired
through active internal and external experiences and includes facts, con-
cepts, and social cognition of one’s own feelings and intentions as well
as the feelings and intentions of others. Social cognition includes under-
standing not only one’s own knowledge of how one feels and how these
feelings cause one to act in certain ways, but also how emotions cause
people to act and how events or people’s behavior can elicit emotions,
which may be explicitly or implicitly communicated (Muma, 1991).
Social communication involves not only competent oral com-
munication but knowledge of what communicative behaviors mean
and effective sociocultural communication of intentions or needs
(Crago & Eriks-Brophy, 1994; T. Gallagher, 1991; Müller, 2000). Com-
municative competence involves comprehension and expression of
the language-specific phonology, syntax, semantics, and pragmatics.
Pragmatic rules are culturally influenced rules for interaction and talk.
Internal and external experiences can be shared with others both non-
verbally (facial expressions, tone of voice, postures, and gestures) and
verbally, which are influenced by sociocultural values that are modeled,
taught, and passed down from generation to generation. These values
are reflected in pragmatic rules for talking. Ninio and Snow (1996)
defined pragmatic language as “the acquisition of knowledge necessary
for the appropriate, effective, rule-governed employment of speech in
6 • Hwa-Froelich

interpersonal situations” (p. 4). Although Oliver demonstrated compe-

tent phonology, he had low average receptive and expressive language
development, which affected his responses to questions and his dis-
course skills. Oliver had not learned how to attend to and interpret oth-
ers’ social communication; respond appropriately to questions; initiate,
maintain, and organize discourse for conversations; or communicate
his intentions appropriately. Oliver demonstrated a primary pragmatic
language disorder or, according to the Diagnostic and Statistical Manual
of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association
[APA], 2013), a social communication disorder (Müller, 2000). In other
words, Oliver did not understand or use pragmatic language rules effec-
tively, resulting in poor social communication and social competence.
Why is social competence important? Without social competence,
individuals have difficulty relating to and connecting with other peo-
ple. This may result in poor relationships with family, friends, teachers,
coworkers, or supervisors. Without successful relationships, individuals
who have poor social competence lead isolated, lonely lives. They may
also struggle in the classroom, which can make attaining and maintain-
ing employment a challenge.
The challenges faced by socially incompetent individuals are not
just anecdotal. Research has provided evidence of negative outcomes
for children with poor social competence (for a review see Ladd, 1999).
Reviewing research on social competence, Ladd reported several studies
in which children’s social competence was correlated with later school
adjustment problems such as truancy, discipline problems, and higher
dropout rates. Several variables may affect social competence and
result in myriad social outcomes. These include parental factors such
as attachment, parental sensitivity, or attunement; friendship variables
such as behaviors that affect acceptance and rejection of peers or facili-
tate friendships; and individual factors such as temperament, gender,
and cultural differences.
With as many variables that play into and affect social competence,
it is not surprising that there is great heterogeneity across individuals
with social competence and social communication disorders. Oliver
represents an example of a child with pragmatic language impairment
that resulted in a mild social competence problem. However, pragmatic
language impairment can be a defining characteristic of a disorder,
such as Autism Spectrum Disorder (ASD) and can co-occur with lan-
guage impairment (LI), and with disorders of social competence such
as Attention Deficit Disorder with or without the Hyperactivity compo-
nent (ADD/ADHD), disruptive behavior disorder (DBD) and children
who have experienced maltreatment.
 Theoretical Foundations and Introduction • 7

THEORETICAL FOUNDATIONS
Several theoretical perspectives provide different explanations for how
social competence, communicative competence, and social communi-
cation competence are acquired. Because social competence includes
culturally influenced social cognition and world knowledge, construc-
tionist and social learning or social interaction theories may be involved.
Theories explaining communicative competence in form, content, and
use, include these constructivist and social learning theories as well as
pragmatic theories. Social communication competence is a coalescence
of the two. It accesses and compares prior world and social knowledge
as well as sociocultural and linguistic rules of form, content, and use
with the current interaction. Theories of information processing, con-
nectionism, and dynamic systems may help to explain within-culture
variability in social communication development and disorders.

Cognitive Constructivist and Social Learning Theories

Cognitive constructivist and social interaction theorists believe that
interaction with one’s world facilitates cognitive, social and communi-
cation learning and development (Hobson, 2004; Vygotsky, 1934/1986).
According to Piaget’s theory of cognitive development (Piaget, 1983),
cognitive development precedes children’s language development, and
certain cognitive stages need to be attained in order for language stages
to be achieved. For example, during the sensory motor stage of develop-
ment, it is after children use sensory motor schema to learn about and
act upon their physical environment that children learn labels associ-
ated with objects and actions.
Some theorists believe that learning occurs within social and cul-
tural contexts (Bandura, 1986; Hobson, 2004; Vygotsky, 1934/1986).
Bandura proposed a social learning theory in that when children are
motivated to learn, they learn by observing and imitating others, and
they expect similar outcomes for themselves following their imitation
of others. Although Vygotsky also believed learning involved social
interaction, it was his view that caregivers mediate children’s learning
to create a zone of proximal development, that is, what a child can do
with adult facilitation and what a child can do independently. In other
words, children’s interaction with the environment is socially facilitated
and provides children developmentally supported learning experiences.
Vygotsky described language as a means for self-regulation. He believed
that language was internalized and was a means by which children regu-
lated their emotions and behaviors. Thus, children learn how to interact
through adult-mediated social and communicative interactions.
8 • Hwa-Froelich

Another social interaction theory is the Transactional model or Inter-

action theory (Gallagher, S., 2013; Sameroff, 1987; Sameroff & Chandler,
1975). In this model, social interaction is bidirectional. The child
interacts with and influences caregivers’ responses, which, in turn, affect
the child’s development. In other words, the transaction of the child with
his or her social environment determines developmental outcomes. The
transactional nature of social interaction is varied among individuals.
Both internal variables (i.e., gender, temperament, neurological devel-
opment) and external variables (i.e., maternal sensitivity, parental input,
birth order) can affect transactional learning, resulting in great develop-
mental variability (Gallagher, S., 2013; Wetherby, 1991).
Friendship theory is related to social learning and interaction with
peers. These relationships normally include familial interactions, but
peer friendships, collaborative learning groups, and group member-
ships are also vital (Sullivan, 1953). Children develop social skills spe-
cific to the different interpersonal contexts they experience to achieve
successful relationships. Initially, children learn how to coexist and play
side by side, then play cooperatively by negotiating and taking on roles
in dramatic play, and eventually develop friendships in which children
prefer and care about another person (Goldstein & Morgan, 2002). As
children mature and become more socially competent, they develop
social and communication skills to participate in cooperative learning
groups. These groups facilitate sharing of ideas, resources, information,
encouragement, and constructive criticism toward the achievement of
group goals or outcomes. These social skills eventually enable adoles-
cents and adults to become functional, contributing members of a wide
variety of social groups.
These theories help to explain how individuals learn and acquire
social competence and acquire communication skills including lin-
guistic form and content. There are additional theories that address the
functions of language or pragmatic language. Communicative compe-
tence involves not only form and content but also knowledge of appro-
priate use of pragmatic language rules.

Pragmatic Theories
Several theorists have described theories associated with the acquisi-
tion of pragmatic rules as well as different types of language use. These
theories include language use, commonly referred to as speech acts, and
conversational implicature or relevance. Pragmatics has been studied in
relation to (a) the use of deixis, (b) the context of the interaction, and (c)
comprehension and use of nonliteral language, discourse, and conversa-
tion (for a review see Cummings, 2009).
 Theoretical Foundations and Introduction • 9

Early theories formulated by Austin (1962) and Searle (1969)

described how expressive language is used for more than merely report-
ing facts or events. Speech acts use language as a means to make prom-
ises, declarations, directions, questions, comments, threats, warnings,
suggestions, and many other purposes (Searle, 1969). Individuals can
differ in terms of the range of speech acts they use, as well as the range
of incorrect comprehension and/or expression of speech acts.
Grice (1975) proposed a theory of conversational implicature, which
was later simplified to a theory of relevance by Sperber and Wilson
(1986). Grice believed there were four maxims that speakers expect dur-
ing conversations with others. These include (a) quality—individuals
should not give false information or unproven information; (b)
quantity—individual contributions should provide just enough infor-
mation, to make a point; (c) relation—contributions should retain the
topic of the conversation; and (d) manner—contributions should be
brief, orderly, and clear (Cummings, 2009). These four maxis were sim-
plified to one theory of relevance in that speakers should try “to be as
relevant as possible” (Wilson & Sperber, 1991, p. 381). Individuals who
have problems with relevance may have difficulty making truthful state-
ments or statements based on fact. They may not give enough infor-
mation to be understood or may give too much information by talking
incessantly. They may digress from the original topic, forgetting what
the topic was, give irrelevant information, or add information that is
unclear. For example, Oliver would often add information unrelated to
the topic during conversation and story retell.
These pragmatic theories focused on language use and assumed com-
petence in other communication areas (form and content). In order to
become competent in social communication, individuals must acquire
knowledge and skills in social competence and communicative compe-
tence. They need to be able to process social and communication stimuli
while accessing past experiences and knowledge to determine and suc-
cessfully execute an appropriate response.

Information Processing, Connectionism,

and Dynamic Systems Theories
Social communication competence involves the ability to interpret
both nonverbal and verbal messages, the context of the interaction,
and the sociocultural interaction rules while planning and managing
one’s behavior during the interaction. This complex skill involves the
processing of incoming information, retrieval of cognitive, social, and
linguistic knowledge, working memory, and executive function skills to
compare and contrast knowledge while attending to the current situation
10 • Hwa-Froelich

and selecting, planning, and monitoring one’s response (Crick & Dodge,

1994). Two theories that help explain this process are information pro-
cessing and connectionism theories. A  third theory, dynamic systems
theory (DST) provides an explanation for the variability across indi-
viduals’ social competence, social cognition, and social communication
development along with associated disorders.
According to the information processing theory, three stages are
involved when appraising information: (a) a sensory memory stage, (b)
a short-term or working memory stage, and (c) a long-term memory
stage (Atkinson & Shiffrin, 1968). According to this theory, individuals
may process stimuli bidirectionally using both bottom-up and top-down
processing during the sensory memory stage. Bottom-up processing
involves an individual’s initial awareness and appraisal of the stimulus’s
emotional value. In top-down processing, individuals perceive, attend,
appraise, and compare stimuli with long-term memories that are associ-
ated with or similar to the stimuli.
From information processing theory, other theories such as
parallel-distributed processing, connectionist, and social information
processing theories have developed. According to parallel-distributed
theory, information from social communicative interactions is processed
by different memory sections of the brain at the same time (Rumel-
hart & McClelland, 1986). In other words, processing is not sequential
but simultaneous involving multiple parts of the brain. Building upon
this theory, connectionist theorists believe that memory is stored in
neural networks across multiple brain locations. Neural networks are
formed when patterns of neural synapses (neural pathways receiving
and simultaneously sending information) are activated. When neural
networks are activated often, the network pattern becomes stronger and
facilitates memory retrieval and generalization of information.
Social information processing theorists agree that processing is often
simultaneous and can occur along parallel pathways. However, they
focus their theory on “conscious rule interpretation” as opposed to hav-
ing an “intuitive processor,” and apply social information processing
to social adjustment development (Crick & Dodge, 1994, p. 77). Crick
and Dodge (1994) described the steps of social information process-
ing when individuals interact with others. First, individuals encode the
cues of the situation internally and externally. The second step involves
an interpretation process during which the cues are interpreted and
evaluated across causes, intentions, and personal and interpersonal
goals. These are compared to memories of past experiences and social
rules. Next, individuals regulate themselves to clarify their own personal
goals as well as the goals of others. Clarification of goals enables them to
 Theoretical Foundations and Introduction • 11

begin the process of selecting a response by searching for and evaluating

choices of behavioral responses, possible outcomes, and their ability to
execute the behavioral choice in order to select and construct a response.
Finally, individuals employ the response while monitoring and regulat-
ing their behavior. The partner in the social interaction responds, and
the process begins again.
These processing and connectionist theories are generally founded
on four assumptions: (a) the brain has capacity limitations constraining
the amount, speed, and efficiency for processing; (b) there is a process
manager or executive function that manages information processing
to encode, transform, process, store, retrieve, and use information; (c)
processing is bidirectional as described earlier; and (d) there are genetic
predispositions to process information in specific ways.

Dynamic Systems Theory

While social learning and social interaction theories help to explain
how learning is socially mediated, information processing and connec-
tionism help to explain the complex neurological processes involved in
interpreting and participating in social interactions. However, none of
these theories explains the individual developmental variability in social
communication outcomes. DST provides a model of dynamic interac-
tion among multiple systems that helps explain the heterogeneity of
social communication disorders.
DST is closely related to connectionist theory and grew from stud-
ies of complex systems in biology, physics, and psychology (Thelen &
Bates, 2003). Recently, DST has been discussed as a theory to explain
emotion development and self-organization (Lewis  & Granic, 2000),
language development and disorders (De Bot, Lowie,  & Verspoor,
2007), and bilingual and disrupted language development and disor-
ders (Hwa-Froelich, 2012; Kohnert, 2008). DST describes humans as
complex systems in which complex interactions with elements of the
system can result in a variety of different developmental patterns and
outcomes. Through developmental processes, each individual experi-
ences transitions during which internal systems destabilize and reor-
ganize in systematic ways. Variables affecting transitions or changes
are interrelated with other variables. Some of the constraining factors
in dynamic systems may include initial system structures, such as neu-
robiological development, exposure to expected experiences, such as
developmentally appropriate interactions with a caring adult; depend-
ent experiences, such as sensitive nurturing interactions with the envi-
ronment; and early emerging foundations of self-organization (Lewis,
1997). Human development is viewed as a nonlinear emergent process
12 • Hwa-Froelich

in which an individual may organize systems around attractor states that

were formed by previous experiences or knowledge. Unstable systems
require less energy to change whereas stable systems need more energy
to change. For example, children diagnosed with ASD may demonstrate
consistent repetitive behaviors at home, which may be an indication
of a stable system with attractor states drawn toward a static, familiar,
and less structured daily life. Consequently they will need more energy
(attention, memory, motivation, and processing speed) to transition and
function within a structured environment (such as school) with struc-
tured routines, rules, and increased novelty. Because variables and con-
straints can freely vary among each other, these variations can result in a
mix of indeterminism and determinism resulting in large differences in
developmental outcomes. Thus, development is not always predictable
in a linear or simple way (Fogel, Lyra, & Valsiner, 1997).
The principles of general systems theory include (a) complex sys-
tems consist of many interdependent parts that dynamically influence
each other; (b) complex systems organize in such a way that behavior of
the system cannot be described in terms of the parts and relationships
of the parts; (c) the unique transactions between the individual and
its relationships create self-organization and stabilization over time;
(d) many different processes can lead to a similar system organization
or equifinality; and (e) systems dynamically create independent but
related hierarchical patterns (Fogel, 1993). The more flexible the sys-
tem, the greater the opportunity to make use of available resources to
adjust to changes.
DST helps explain the heterogeneity and highly varied range of social
behaviors and social communication performance across social com-
munication disorders. The many involved variables as well as the multi-
ple ways humans may self-organize may explain the variability in indi-
vidual developmental outcomes. In Oliver’s case, he possessed adequate
cognitive and communication skills to help him learn and apply social
communication strategies with peers and family members. Early inter-
vention focused on learning the meaning and intention of questions,
explicitly teaching pragmatic strategies for initiating interactions, main-
taining topics in conversations, and taking turns during play with peers
and conversations with adults. Sequential pictures and visual cues were
used and later faded to help Oliver learn how to organize his discourse
in retelling stories. After a year of early intervention, Oliver learned how
to answer questions, initiate social and communicative interactions,
take turns, initiate, change, and maintain topics in conversation and was
able to organize his discourse in storytelling and conversations in a logi-
cal sequence.
 Theoretical Foundations and Introduction • 13

Early intervention enabled Oliver to develop the necessary skills to

achieve social communicative competence. Other children may dem-
onstrate a more complex picture of social competence and social com-
munication, which may be challenging for professionals working with
individuals with social communication disorders. The purpose of this
book is to provide information about developmental areas related to
social competence and social communication as well as individual
chapters devoted to evidence-based assessment and intervention prac-
tices for children with social communication disorders.

BOOK ORGANIZATION
The purpose of this book is to provide two perspectives of social com-
munication. One perspective is that of a developmental nature. To
understand atypical development, it is important to understand typi-
cal social communication development. The second perspective is a
clinical one. The second section of this book focuses on a review of
evidence-based practices for assessment and treatment of social com-
munication disorders.

Evidence-Based Practice
What is evidence-based practice (EBP)? EBP has been defined as
“the integration of best research evidence with clinical expertise and
patient values” (Sackett, Strauss, Richardson, Rosenberg,  & Haynes,
2000, p.1). Based on this definition, to provide EBP, professionals
must integrate clinical expertise and/or expert opinion with the best
available scientific evidence while considering the values of the client,
patient, and/or caregiver. By doing so, it is more likely that practition-
ers will provide high-quality services that also reflect the individual
interests, values, and needs of their clients and families. The American
Speech-Language-Hearing Association (ASHA; 2013) describes the
clinical process of providing EBP as consisting of four steps: (1) fram-
ing the clinical question, (2) finding the evidence, (3) assessing the evi-
dence, and (4) making a clinical decision (ASHA, 2013). To frame the
clinical question, practitioners consider the population, interventions,
comparisons, and outcomes (PICO). The clinical question is based on
the particular individual factors associated with a client or group of
clients. These factors may include but are certainly not limited to such
factors as age, gender, socioeconomic status, language history, and type
of communication disorder. The interventions may include different
therapeutic strategies or models and comparisons of these strategies or
14 • Hwa-Froelich

models across populations or types and severity levels of disorders. The

outcome would be the effectiveness of the particular treatment strat-
egy or model on the particular disorder or clinical question. Assessing
outcomes involves the level of evidence available to answer the clinical
question (ASHA, 2013).
The second step of EBP is finding the evidence to answer the clini-
cal question. There are two kinds of evidence, systematic reviews,
and individual studies. Systematic reviews are formal studies, such
as meta-analyses that review high-quality evidence. High-quality evi-
dence can include meta-analyses of randomized controlled studies,
quasi-experimental design studies, and single-subject design stud-
ies. ASHA (2013) provides several websites where systematic reviews
of studies on communication sciences and disorders can be found.
However, sometimes, these systematic reviews are not available for
all clinical questions. In this case, practitioners may search for indi-
vidual studies of high quality. The levels of evidence from highest
quality to lowest quality include (1) randomized control trial study;
(2) well-designed, controlled study without randomization; (3) well-
designed, quasi-experimental design study; (4) well-designed non-
experimental correlational or case/single-subject design study; and (5)
expert committee report, consensus conference, or clinical experience
of respected authorities (ASHA, 2013).
Once the evidence has been located, the practitioner must assess the
evidence. It is important to check that the evidence is relevant to the
particular clinical question. In addition, the practitioner should review
the authors of the research to assess to what extent potential for investi-
gator bias is possible. Sometimes advocacy groups or groups who may
receive financial benefit are the authors of research, which may affect
their collection and interpretation of the data. Subsequent to this review,
the practitioner should complete a critical review of the study design
and efficacy of the interventions.
The fourth and final step in EBP is make a clinical decision. Clini-
cal decision making involves integrating the research evidence, clinical
expertise, and the client’s values, goals, and needs to provide individual-
ized services of high quality. Taking the best research evidence available
and interpreting this evidence through a research lens of efficacy, a clini-
cal lens of effectiveness, and clinical applicability in accordance with the
client’s preferences and needs is pulling all the components and EBP steps
together. By implementing this practice, the practitioner is more likely
to provide high-quality interventions and see more positive outcomes.
However, the practitioner must also measure client outcomes prior to,
during and following application of EBP to insure the effectiveness of
 Theoretical Foundations and Introduction • 15

their clinical intervention. This process ensures that clinical application

is truly effective with their client’s particular values, goals, and needs.

Book Organization
Several developmental areas form the foundations for social competence.
These include neurological, social-emotional, cognitive processing, and
social communication development. The first section of this book includes
chapters on social neuroscience, social and emotional development,
development of related cognitive processes, and social communication
development. Carol Westby, PhD, is a Board-Certified Child Language
Specialist and an ASHA Honors recipient, who has published and pre-
sented extensively on social communication development and disorders.
She is currently a consultant/supervisor for Bilingual Multicultural Ser-
vices and is designing a program to facilitate social-emotional develop-
ment. She wrote Chapter  2, which describes the neurological science
associated with social processing, learning, and communication. Debo-
rah Hwa-Froelich is a professor in the Department of Communication
Sciences and Disorders at Saint Louis University, and her research focuses
on sociocultural, socioeconomic, and social-emotional factors influenc-
ing communication development and disorders. She is also the founder
and consultant for the International Adoption Clinic at Saint Louis Uni-
versity. Dr. Hwa-Froelich, PhD, wrote Chapter 3, which describes social
and emotional development; Chapter 4, which focuses on the develop-
ment of cognitive processes; and Chapter 5, which explains social com-
munication development. The chapter on social-emotional development
includes such topics as attachment, attunement, emotion development,
and self-regulation. The chapter on cognitive processes involved with
social communication development discusses attention, social cognition,
memory, and executive function development. Finally Chapter 5 focuses
on social communication development including intersubjectivity, non-
verbal communication, verbal communication, and pragmatic language
development. The chapters in Section I include a case study and a descrip-
tion of variables that may affect social communication development.
Each chapter in the second section of the book includes a case study,
incidence, and prevalence estimates, the current DSM-5 definition of
the disorder, referral guidelines, recommended practices of assessment
and intervention, and a list of clinical resources. Specialists with clini-
cal and research experience specific to social communication disorders
have written these chapters. Catherine Adams, PhD, is a senior lecturer
at the University of Manchester with extensive research and clinical
experience with children who have a Pragmatic Language Impairment.
Currently she is completing a randomized controlled trial study studying
16 • Hwa-Froelich

intervention efficacy for children with pragmatic language impair-

ment. Dr.  Adams wrote Chapter  6, Assessment and intervention
for children with Pragmatic Language Impairment. Chapter  7 was
coauthored by Danai Kasambira Fannin, PhD, an assistant professor
in communicative disorders at Northern Illinois University, and Linda
Watson, EdD, a professor at the University of North Carolina. Dr. Fan-
nin was a postdoctoral fellow who worked with Connie Kasari, PhD,
at the Neuropsychiatric Institute at University of California, Los Ange-
les. Her research interests include  the development of evidence-based
autism treatment, with a focus on providing appropriate evaluation and
intervention for culturally and linguistically diverse children and their
families. Dr. Watson has published and presented extensively on ASD and
currently is a co-investigator on a federally funded project studying inter-
vention efficacy of social programs and children with ASD. Chapter 7,
Social communication assessment and intervention for children on the
Autism Spectrum, focuses on children with ASD. Bonnie Brinton, PhD,
and Martin Fujiki, PhD, are professors in the department of communica-
tive disorders at the University of Brigham Young. Dr. Brinton special-
izes in assessment and intervention with children with social commu-
nication disorders and Dr. Fujiki conducts research in social-emotional
competence in children with language impairment. They coauthored the
chapter Social communication assessment and intervention for children
with language impairment (Chapter 8). Geralyn Timler, PhD, an assis-
tant professor and Katherine E. White, a graduate student and director of
the Child Language and Social Communication Lab at Miami University
wrote Chapter 9, which describes evidence-based practice for children
with attention disorders. Dr.  Timler has research and clinical interests
focusing on social communication and pragmatic skills in children with
Fetal Alcohol Spectrum Disorders, Specific Language Impairment, Atten-
tion Deficit Hyperactivity Disorder (ADHD), and ASD. Dr. Hwa-Froelich
wrote Chapter  10, which describes social communication assessments
and interventions for children exposed to maltreatment, and Dr. Westby
wrote Chapter 11, which focuses on social communication assessment
and treatment for children with Disruptive Behavior Disorders (DBD).

DISCUSSION QUESTIONS
1. What skills and knowledge does one need to have competent
social communication?
2. Why are social communication and social competence important?
3. What theories help to explain social communication?
 Theoretical Foundations and Introduction • 17

4. Which theory offers the best explanation for the heterogeneity

of social communication disorders, and why?

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 2
SOCIAL NEUROSCIENCE
Carol E. Westby

And yet what are we to do about this terribly significant business of

“other people,” so ill-equipped are we all to envision one another’s inte-
rior workings and invisible aims?
—Philip Roth, in American Pastoral

I know you think you understand what you thought I said but I’m not
sure you realize that what you heard is not what I meant.
—Alan Greenspan

LEARNING OBJECTIVES
Readers will be able to
1. Describe the dimensions or types of theory of mind.
2. Identify the neuroanatomical areas associated with the different
dimensions of theory of mind.
3. Explain the ways the environment and genetics influence neu-
roanatomical/neurochemical functioning.
In the chapter-opening quotations, Philip Roth, the American novelist
noted for his characterizations, asks how we are to understand the intents
of others. Alan Greenspan, the American economist who was the chair-
man of the US Federal Reserve, questions our ability to understand his
intent and meaning. Processing Roth’s and Greenspan’s statements requires
social understanding and what has been termed a “theory of mind.”

20
 Social Neuroscience • 21

The term theory of mind (ToM) was introduced by Premack and Wood-
ruff (1978) when they asked, “Does the chimpanzee have a theory of
mind?” They defined ToM as the ability to impute mental states to oneself
and others. This began a new direction in psychology—from an emphasis
on cognition to an emerging investigation of social skill. Current research
in neuroscience is explaining how the brain functions when processing
cognitive and social information. This chapter reviews current research in
social neuroscience, particularly the research in the neuroanatomical and
neurochemical underpinnings for ToM and related behaviors.

WHAT IS SOCIAL NEUROSCIENCE?

History of Social Neuroscience
The technologies of the 1970s and 1980s made possible the fields of cog-
nitive and social science as we now know them. Cognitive neuroscience
focused on the neural substrates of memory, language, and spatial percep-
tion and their behavioral manifestations. The emphasis was on nonsocial
aspects of cognition. Social neuroscience is a term applied to an emerging
field of study concerned with identifying the neuroanatomy, neurochem-
istry, and neural processes underlying social behavior or social cogni-
tion. Using methods and theories of neuroscience, social neuroscience
seeks to better understand the relationship between the brain and social
behavior (Decety  & Keenan, 2006; Waldrop, 1993). This relationship is
reciprocal: the brain affects social cognition and behavior, and social
cognition/behavior affects the brain (Insel & Dernald, 2004). The field of
social neuroscience has emerged in just the last few years. The first issues of
the journals Social Neuroscience and Social Cognitive and Affective Neu-
roscience were published in 2006. The international, interdisciplinary
Society for Social Neuroscience was launched in January 2010. The term
social neuroscience first appeared in an article by Cacioppo and Bertson
(1992) who proposed that social psychology and neuroscience represent
two ends of a continuum of levels of organization studied in psychology.
Understanding social behaviors must acknowledge research demonstrat-
ing both that (a) neuroanatomical/neurochemical events influence social
processes and (b) social processes influence neuroanatomical/neuro-
chemical events. Recent work in epigenetics is demonstrating how envi-
ronmental factors influence gene expression which can influence social
behavior. Epigenetics is the study of heritable changes in gene activity
that are not caused by changes in the DNA sequence. The first issue of
Epigenetics and Chromatin was published in 2008. Epigenetic discoveries
reveal that social factors such as environmental, dietary, behavioral, and
22 • Westby

medical experiences can significantly affect the development of an indi-

vidual (including ToM understanding) and sometimes his or her offspring.

Social Neuroscience Methods

A number of methods are used in cognitive and social neuroscience
to investigate the confluence of neural, cognitive, and social processes.
These methods draw from behavioral techniques developed in social
psychology, cognitive psychology, and neuropsychology and are asso-
ciated with a variety of neurobiological techniques including func-
tional magnetic resonance imaging (fMRI), magnetoencephalography
(MEG), positron emission tomography (PET), facial electromyography
(EMG), transcranial magnetic stimulation (TMS), electroencepha-
lography (EEG), event-related potentials (ERPs), electrocardiograms,
electromyograms, endocrinology, immunology, galvanic skin response
(GSR), single-cell recording, and studies of focal brain lesion patients.
These neurobiological methods can be grouped together into ones that
measure more external bodily responses, electrophysiological methods,
hemodynamic measures, and lesion methods. Bodily response methods
include GSR (also known as skin conductance response [SCR]), facial
EMG, and the eyeblink startle response. Electrophysiological methods
include single-cell recordings, EEG, and ERPs. Hemodynamic measures,
which, instead of directly measuring neural activity, measure changes in
blood flow, include PET and fMRI. Lesion methods traditionally study
brains that have been damaged via natural causes, such as strokes, trau-
matic injuries, tumors, neurosurgery, infection, or neurodegenerative
disorders. In its ability to create a type of “virtual lesion” that is tempo-
rary, TMS may also be included in this category (Ward, 2012).

Assessing Theory of Mind

Deficits in ToM are characteristic of nearly all, if not all, social-emotional
difficulties including deficits in social communication. Once Premack
and Woodruff (1978) introduced the term theory of mind, it was rap-
idly adopted by developmental psychologists. By the late 1980s and early
1990s, deficits in ToM became associated with autism spectrum disorder
(ASD; e.g., Baron-Cohen, 1995). But ToM deficits and delays in devel-
oping ToM are not limited to those with ASD. Deficits in ToM underlie
many of the social communication difficulties exhibited not only by per-
sons with ASD but also by persons with other communication disorders
(e.g., language impairment, deafness, attention-deficit hyperactivity dis-
order, traumatic brain injury, Parkinson’s disease, dementia), behavio-
ral disorders, and psychiatric conditions, as well as children who have
experienced abuse and neglect (Baron-Cohen, 2011; Perry, 2011).
 Social Neuroscience • 23

Until the early 2000s, most of the research on ToM was at the behavio-
ral psychological or cognitive level—how persons performed when given
tasks that required them to reflect on the knowledge, thoughts, and beliefs
of others. ToM, however, extends beyond mentalizing about cognitive pro-
cesses of knowing, thinking, and believing. ToM also involves reflecting
on the emotions of oneself and others and appropriately responding to or
empathizing with the emotions of others. With the advent of social neuro-
science and epigenetics, an increasing number of studies have investigated
the neuroanatomical and neurochemical functions associated with these
behavioral activities and how environmental factors may influence neu-
roanatomical and chemical functioning. This research has revealed that
ToM is not a unitary construct; there are several different dimensions or
types of ToM, each having differing neuroanatomical and neurochemical
underpinnings (Abu-Akel & Shamay-Tsoory, 2011; Frith & Frith, 2003;
Northoff et al., 2006; Shamay-Tsoory, 2011). Although there can be over-
lap in regions of the brain involved in the different types of ToM, specific
brain areas are critical for performance of particular dimensions of ToM.
In investigating ToM, researchers have studied how differing individu-
als perform a variety of ToM tasks—neurotypical individuals, individuals
who have had circumscribed brain insults (strokes, tumors, penetrating
wounds), individuals with different diagnoses (autism, schizophrenia,
behavioral disorders), and persons of different ages. This research pro-
vides evidence for the distinctions among several types of ToM:
• Cognitive ToM: The ability to attribute mental states—beliefs,
intents, desires, pretending, knowledge, and so on—to oneself
and others and to understand that others have beliefs, desires,
and intentions that are different from one’s own.
• Affective ToM: Process of recognizing one’s own emotions or
inferring the affective states of others by sharing their emotions
and by understanding the other’s emotions. Affective ToM can
be subdivided into the following:
° Affective cognitive ToM or cognitive empathy: Recognition/
identification one’s own emotions and the emotions of others
° Affective empathy: The capacity to respond with an appropri-
ate emotion to another’s emotion.
• Interpersonal ToM: Cognitive and affective ToM for others
(recognizing thoughts and emotions of others and making
inferences about them).
• Intrapersonal ToM: Cognitive and affective ToM for oneself (a
sense of self and reflecting on one’s own thoughts and emotions
and using this information to learn and plan).
24 • Westby

Theory of Mind

Affective
Cognitive
Affective Cognitive
Affective Empathy

Interpersonal/ Intrapersonal/
social reflective

Recognizing Responding Reflecting on Planning &

Making
thoughts & empathically one’s own regulating
inferences about
emotions of to others thoughts & one’s own
behaviors,
others thoughts & emotions behaviors/
emotions of emotions
others

Figure 2.1 Dimensions of Theory of Mind

See Figure 2.1, which shows the dimensions of ToM.

Evidence for the neural bases of cognitive and affective ToM has
come from two sources: functional imaging studies of normal partici-
pants and patients with brain injuries. Shamay-Toorsy and colleagues
(Abu-Akel & Shamay-Tsoory, 2011; Shamay-Tsoory, & Aharon-Peretz,
2007; Shamay-Tsoory, Hararib, Aharon-Peretz,  & Levkovitzbet, 2010;
Shamay-Tsoory, Tibi-Elhanany, & Aharon-Peretz, 2007) have probably
the most extensive set of studies on the neuroanatomical bases of cogni-
tive and affective ToM. In several studies they have asked participants to
judge mental or emotional states based on verbal and eye gaze cues of
a cartoon figure. The task consists of 64 trials, each showing a cartoon
outline of a face (named “Yoni”) and four colored pictures of objects
belonging to a single category (e.g., fruits, chairs), one in each corner of
the computer screen. (View the materials at http://sans.haifa.ac.il/Dow
nloads.html). The participant’s task is to point to the image to which Yoni
is referring, based on a sentence that appears at the top of the screen and
available cues, such as Yoni’s eye gaze, Yoni’s facial expression, or the eye
gaze and facial expression of the face to which Yoni is referring. There
are two main conditions: “cognitive” and “affective,” requiring either a
first-order (what someone is thinking/feeling) or a second-order (what
someone is thinking/feeling someone else is thinking/feeling) inference.
In the cognitive conditions, both Yoni’s facial expression and the verbal
cue are emotionally neutral, whereas in the affective conditions, both
cues provide affective information (i.e., Yoni is thinking of [cognitive
 Social Neuroscience • 25

condition] versus Yoni loves [affective condition]). Whereas the cogni-

tive condition requires understanding beliefs about others’ beliefs and
desires (Yoni is thinking of the toy that ___ wants), the affective condi-
tion involves understanding of one’s emotions in regard to the others’
emotions (Yoni loves the toy that ___ loves).
Neuroscience studies have shown that attributing emotional states to
oneself and others involves some different neuroanatomical areas than
attributing mental states to oneself and others. Attributing emotional
states to oneself and others is termed affective ToM. Affective ToM has
two components: an affective cognitive component (sometimes termed
cognitive empathy) that involves an awareness or recognition of one’s
own feelings or the feelings of others and an affective empathy (emo-
tional empathy) component that involves the ability to experience
the emotions of others. Affective empathy is elicited by the perceived,
imagined, or inferred affective state of another and includes some cog-
nitive appreciation of the other’s affective state comprising perspective
taking, self–other distinction, and knowledge of the causal relation
between the self and the other’s affective state (Walter, 2012). Affec-
tive empathy includes some meta-knowledge about self and the other
that distinguishes it from emotional mimicry and emotional contagion.
Emotional mimicry is defined as automatic synchronization of emo-
tional behavior, for example, affective expressions, vocalizations, pos-
tures, and movements with those of another person—one yawns when
seeing another yawn. Emotional contagion occurs when people expe-
rience emotions similar to those of others by mere association. Emo-
tional mimicry and contagion require neither perspective taking nor
an explicit self–other distinction. It can be difficult to know whether a
person is really experiencing affective empathy or is instead displaying
emotional mimicry or emotion contagion.
Over the years, the majority of studies on ToM have focused on
performance on cognitive ToM tasks. These have investigated persons’
ability to attribute mental states—beliefs, intents, desires, pretend-
ing, knowledge, and so on—to oneself and others and to understand
that others have beliefs, desires, and intentions that are different from
one’s own. The term theory of mind has typically been applied to pass-
ing of cognitive ToM tasks involving false belief about contents (e.g.,
M&Ms in a crayon box) or locations (a toy is moved to a new loca-
tion). In a false-belief-contents task, children are shown a crayon box
and asked what they think is with inside. After the children guess, they
are shown that their prediction was wrong—the crayon box contains
candy. The experimenter then recloses the bag or box and asks the chil-
dren what they think another person, who has not been shown the
26 • Westby

true contents of the box, will think is inside. The children pass the task
if they respond that another person will think that there are crayons
in the crayon in the box but fail the task if they respond that another
person will think that the crayon box contains candy (Gopnik  &
Astington, 1988).
In the most common version of the false-belief-locations task (often
called the Sally–Anne task), children are shown two dolls, Sally and
Anne, who have a basket and a box, respectively. Sally also has a marble,
which she places in her basket, and then leaves the room. While she
is out of the room, Anne takes the marble from the basket and puts it
in the box. Sally returns, and the child is then asked where Sally will
look for the marble. Children pass the task if they answer that Sally will
look in the basket, where she put the marble; children fail the task if
they answer that Sally will look in the box, where the children know the
marble is hidden, even though Sally cannot know this, because she did
not see it hidden there. For both of these tasks, children must be able
to understand that another’s mental representation of the situation is
different from their own, and the child must be able to predict behavior
based on that understanding. Typically developing children pass these
tasks between ages 4 or 5.
Shamay-Toorsy and colleagues (Shamay-Tsoory, Aharon-Pretz,  &
Perry, 2007; Shamay-Tsoory, Tomer, & Aharon-Peretz, 2005) have also
developed a variety of vignettes that require participants to employ
first-order and second-order cognitive or affective ToM. For example,

Joe and Anna are setting the table for a festive dinner in the dining
room. Anna pours Joe a glass of water, but some water spills on his
new shirt. Joe says: “It’s nothing, I will change the shirt later.” Anna
puts the glass on the table and goes to look for a paper towel to dry
Joe’s shirt. When she leaves the dining room, Joe takes his handker-
chief and dries the shirt and the table. Anna peeks into the dining
room, sees what Joe is doing, and so she doesn’t bring a paper towel.
Anna returns to the dining room.

The participants were then asked,

1. What does Joe think that Anna thinks about the shirt’s condi-
tion, when she returns to the dining room? (second order)
2. What does Anna think of the shirt’s condition? (first order)
In the affective false-belief task, the setting is the same, but this time
when Anna leaves the dining room, Joe gets furious about the wet shirt
and kicks the table. Anna peeks into the dining room, sees what Joe is
doing and feels guilty.
 Social Neuroscience • 27

This time participants are asked,

1. What does Joe think that Anna feels about the wet shirt, when
she returns? (second order)
2. What does Anna think Joe feels about the wet shirt? (second
order)
3. How does Joe feel? (first order)
Participants also responded to questions about vignettes that required
them to interpret higher order ToM involving lies and sarcasm, for
example,
• a cognitive lie—stealing someone’s iPad, then telling him you
haven’t seen it and have no idea where it is;
• an affective lie—telling your grandmother that her meatloaf is
delicious, even though you hate it;
• a cognitive sarcasm ToM—a man walks into a very messy office
and says, “You’re office is so tidy”;
• an affective sarcasm ToM—a father forgets to pick up his son
after school, leaving him in the rain for some time. When the
father and son finally get home, the mother says to the father,
“You are such a good father.”
Performing tasks that require participants to mentalize about people’s
thoughts and beliefs (cognitive ToM) consistently result in activation
of the temporal parietal junction (TPJ; bilaterally, but especially the
right), the dorsal lateral prefrontal (dLPFC) and dorsal medial prefron-
tal (dMPFC) cortex, and the dorsal anterior cingulate cortex (dACC).
When mentalizing about people’s emotions (affective cognitive ToM),
the TPJ is also involved, but in addition, the orbital frontal cortex (OFC),
the inferior lateral frontal cortex (ILFC), the ventral medial prefrontal
cortex (vMPFC), and the ventral anterior cingulate cortex (vACC) are
activated. (See Figure  2.2.) These areas have direct connections into
the insula cortex (which is folded deeply within the lateral sulcus), the
midcingulate cortex, and the amygdala, which are involved in affec-
tive or emotional empathy. Because of its multiple connections to other
brain areas, the vMPFC is an important relay station between cognitive
and affective processing. It is connected to and receives input from the
ventral tegmental area in the midbrain, the amygdala, the temporal lobe,
the olfactory system, and the dorsomedial thalamus and, in turn, sends
signals to the temporal lobe, the amygdala, the lateral hypothalamus, the
hippocampal formation, the cingulate cortex, and the other regions of
the prefrontal cortex. This network of connections enables the vMPFC
to receive and monitor large amounts of sensory data and to influence
many other brain regions, particularly the amygdala, which is highly
28 • Westby

dLPFC TPJ
IPL
IFG
lcus
l Su STS
era
Lat
OFA
TP

PCun
PCC MCC
dACC dMPF

vACC vMPF
HIP

FFA OFC

Figure 2.2 Brain areas involved with Theory of Mind. Cognitive ToM: dACC (dorsal anterior
cingulate cortex); LPF (dorsal lateral prefrontal cortex); dMPF (dorsal medial prefrontal cortex); STS
(superior temporal sulcus); TPJ (temporal pariental junction). Affective ToM: IFG (inferior frontal
gyrus); OFA (occipital facial area); OFC (orbital frontal cortex); vMPF (ventromedial prefrontal
cortex). Intrapersonal ToM: PCun (precuneus); PCC (posterior cingulate cortex); middle cingulate
cortex (MCC); vMPF (ventromedial prefrontal cortex); vACC (ventral anterior cingulate cortex).
Facial processing: occipital facial area (OFA); fusiform facial area (FFA); superior temporal sulcus
(STS). Episodic memory: hippocampus (HIP), posterior cingulate cortex (PCC), inferior parietal
lobule (IFP), & medial frontal (MPF)

involved in emotional processing (Abu-Akel, & Shamay-Tsoory, 2011;

Shamay-Tsoory et al., 2005; Shamay-Tsoory & Aharon-Pretz, et al., 2009;
Shamay-Tsoory, Tibi-Elhanany, et al., 2007). By integrating this range
of information, the vMPFC plays a role in the inhibition of emotional
responses and the process of decision making, particularly social and
moral decision making (Bechara, Tranel,  & Damasio, 2000). Persons
with damage to the vMPFC can make hypothetical moral judgments
without error but cannot apply the same moral principles to similar
situations in their own lives. Social moral decision making requires an
integration of cognitive and affective ToM for others and for oneself.
 Social Neuroscience • 29

THEORY OF MIND PROCESSING

Affective Cognitive ToM and Affective Empathy
When typically developing persons witness another person in physical
or psychological pain, they have an empathic response—they feel the
sadness, anger, or pain of the person they are observing. It is possible to
have a cognitive awareness of the emotions of others (affective cognitive
ToM) without having an empathic response to their emotions (affective
empathy). For example, one might recognize that persons are sad or
feeling pain but not feel sadness with them. Neurotypical persons are
also likely to experience empathic responses when watching a well-acted
film or reading a book with vivid characters. Deficits in affective empa-
thy are a primary diagnostic characteristic of persons with psychiatric
personality disorders (e.g., antisocial personality disorder and conduct
disorders with callous-unemotional traits) (American Psychiatric Asso-
ciation [APA], 2013; Baron-Cohen, 2011). Deficits in empathy are char-
acteristic of persons with autism, even those with Asperger’s syndrome
who typically develop some degree of cognitive ToM.
Shamay-Tsoory and colleagues (Shamay-Tsoory et al., 2009) explored
the neurological foundations for affective cognitive ToM versus affec-
tive empathy ToM. They compared the performance of persons with
lesions in the vMPF cortex or the inferior frontal gyrus with two con-
trol groups—a healthy group and a group with lesions outside the frontal
lobes on tasks measuring emotion recognition, second-order false belief,
and affective cognitive and emotional empathy. The researchers admin-
istered the Interpersonal Reactivity Index (Davis, 1983) which meas-
ures both components of empathy. The affective cognitive items involve
perspective taking or the ability to transpose oneself into fictional situ-
ations. The affective empathy items tap persons’ feelings of warmth, com-
passion, or concern for others or feelings of anxiety or discomfort from
tense interpersonal settings. Participants rated each item of the Index in
terms of how well it described them. An affective cognitive item is “I try
to look at everybody’s side of a disagreement before I make a decision.”
An affective empathy item is “When I see someone being taken advantage
of, I  feel kind of protective towards them.” The researchers found that
subjects with lesions in the vMPFC to be specifically impaired in affective
cognitive ToM (cognitive empathy), whereas patients with IFG lesions
were specifically impaired in affective empathy and emotion recognition.
Experimental evidence suggests that motor simulation may be a trig-
ger for the simulation of associated feeling states or affective empathy.
The discovery of mirror neurons in the inferior frontal and inferior pari-
etal regions of the brain (Rizzolatti, Fadiga, Gallese,  & Fogassi, 1996)
provided new insights into possible explanations for the ability to imi-
30 • Westby

tate and to empathize. A mirror neuron is a neuron that fires both when
an animal acts and when the animal observes or hears the same action
performed by another; hence, they act as a bridge between the self and
the other. Mirror neurons respond not just to the motor properties of an
action but also to the goal of the action. Thus, the neuron “mirrors” the
behavior or intent of the other, as though the observer were itself acting.
Researchers who support a simulation theory explanation of ToM
maintain that mirror neurons can explain the early development of affec-
tive ToM and are involved in empathy (Decety  & Jackson, 2004; Key-
sers, 2011). According to simulation theory, ToM is activated because we
subconsciously empathize with the person we’re observing and imagine
what we would desire and believe in that scenario. The mirror neurons
may account for the emergence of the precursors to affective ToM when
the infant demonstrates emotional contagion (crying when other infants
cry) and emotional mimicry or emotional sharing (imitating the emo-
tional expressions of others). Keysers and Gazzola (2006, 2007) have
shown that people who are more empathic according to self-report ques-
tionnaires have stronger activations both in the mirror system for hand
actions and in the mirror system for emotions, providing more direct
support for the idea that the mirror system is linked to empathy. Walter
(2012) suggested that there are two possible roads to affective empathy:
a low road and a high road. For the low road, features indicating affec-
tive states or suffering (facial expressions, body movements, blood, or
injuries) might trigger emotional contagion and mimicry (via the mirror
neurons) and lead more or less to automatic empathic responding in a
bottom-up manner. With the high road to empathy, empathic responses
are induced top-down by higher cognitive processes. The observer draws
inferences about the thoughts and feelings of another based on con-
textual or situational information, for example, knowing that a friend
wrecked his new car or that your brother just won a scholarship.

Facial Processing
Interpersonal ToM, particularly affective ToM, makes use of reading
faces and bodies when making inferences about others. Precursors to
affective cognitive ToM emerge when joint attention behaviors begin to
appear by 6 months (Mundy & Newell, 2007). Processing of faces can
be divided into perceptual processing which involves distinguishing dif-
ferent facial configurations and conceptual processing which involves
understanding the meaning linked to particular facial expressions. These
processes involve subcortical and cortical pathways. A subcortical path-
way is involved in detecting faces and directing visual attention to them;
and a cortical pathway is involved in the detailed visual-perceptual anal-
ysis of faces. Both of these components interact in the conscious process-
 Social Neuroscience • 31

ing of the emotions and intentions of others (Gobbini & Haxby, 2007).

Three regions in both the left and right hemispheres of the cortex are
critical in facial processing: the occipital face area (OFA), the fusiform
face area (FFA), and the superior temporal sulcus (STS; Haxby, Hoff-
man, & Gobbini, 2000). The OFA is located in the inferior occipital gyrus.
(See Figure 2.2.) It is an early stage in perceptual analysis of faces that sends
inputs to the fusiform and superior temporal regions. It shows greater
fMRI response to faces relative to other categories. The OFA activity is
sensitive to any physical change in the stimulus. The FFA area responds
to faces more than other stimuli and is particularly important for recog-
nizing familiar faces. The STS responds to changeable aspects of a face,
particularly poses and gaze directions, whereas the FFA responds to sta-
ble aspects of the face (the person’s identity). These changeable aspects
are particularly important for extracting social cues that are likely to be
fleeting (Allison, Puce, & McCarthy, 2000). Recognizing invariant facial
features is critical for identifying persons and noting dynamic facial fea-
tures provides information regarding the mental and emotional states of
others. Lesions in these areas disrupt facial processing. In young children
and illiterate persons, more of the facial processing is done by these areas
in the left hemisphere. As persons become literate, these areas are acti-
vated by processing print and facial processing moves more to the right
hemisphere (Dehaene, 2013; Dundas, Plaut, & Behrmann, 2013).
There is some evidence that newborns’ orientation to faces is mediated
by the subcortical visual pathway (Tomalski, Csibra,  & Johnson, 2009).
The eyes carry considerable information about persons’ emotional states.
One must be looking at eyes if one is to interpret eye information. Sev-
eral studies have shown that adults and young children with ASD look
more at the mouth, other body parts, or objects in the environment rather
than at the eyes (Klin & Jones, 2008; Rice, Moriuchi, Jones, & Klin, 2012).
A recent study conducted eye-tracking measures of infants/toddlers who
were low or high risk for autism between 2 and 24 months of age (Jones &
Klin, 2013). Children with siblings diagnosed with autism were considered
high risk. All children showed similar patterns of eye fixation in the first
2 months, but for those children later diagnosed with ASD they began to
exhibit a decline in eye fixation from 2 to 6 months, a pattern that was not
observed in children who did not develop autism. Perhaps this change in
eye tracking in neurotypical infants after 2 months may be related to a
switch from subcortical to cortical processing of visual stimuli.
The deficits in face and emotion recognition reported in people with
ASD do not appear to be due to functioning of the cortical visual areas
(Weigelt, Koldewyn, & Kanwisher, 2012). Instead, these facial process-
ing deficits seem more likely to be due to underconnectivity between the
posterior facial recognition areas and anterior frontal areas, particularly
32 • Westby

the medial prefrontal area responsible for interpretation of the facial

information. There is evidence from diffusion tensor imaging that chil-
dren with ASD show areas of decreased white matter integrity (Schipul,
Keller, & Just, 2011). Specifically, reduced white matter connectivity has
been found between the fusiform face area and frontal area and the pos-
terior superior temporal area and medial frontal cortex (Just, Keller, &
Kana, 2013). Thus, persons with ASD perceive the visual information
similarly to those without ASD, but they fail to interpret the information
appropriately.

Interpersonal and Intrapersonal ToM

Cognitive and affective ToM can be either interpersonal, which involves
recognizing thoughts and emotions of others and making inferences
about them or intrapersonal which involves having a sense of self, and
reflecting on one’s own thoughts and emotions, regulating one’s emo-
tions, and using this information to learn and plan. Lucariello and col-
leagues (Lucariello, Le Donne, Durand, & Yarnell, 2006) compared deve-
lopment of interpersonal and intrapersonal ToM by asking children to
respond to vignettes that required cognitive and affective reflection on
others or on oneself. See Table 2.1.
Researchers have used neural imaging to investigate neural func-
tioning for a variety of self-referential tasks involving verbal, spatial,
social, emotional, or memory processing (Northoff et  al., 2006). Kana
and colleagues (Kana, Klein, Klinger, Travers,  & Klinger, 2013) had
high-functioning adults with autism and neurotypical adults make
yes–no decisions about whether visually presented adjectives (e.g., smart,

Table 2.1 Interpersonal and Intrapersonal Theory of Mind

Interpersonal Intrapersonal

Cognitive • Mary plays a trick on • Ask child if he/she prefers

Sam, whose favorite snack M&Ms or toothpaste. C says
is M&Ms. Mary puts M&Ms and is then handed a
M&Ms in toothpaste box wrapped box. C unwraps and
and puts box on Sam’s table. sees toothpaste box. C opens box
What will another kid think is and finds M&Ms.
in the box before opening it? • What does it look like is in the
What did Sam think was box? What is really in the box?
inside the toothpaste box • What did you think was inside the
before opening it? toothpaste box before opening it?
Affective • How did Sam feel about • How did you feel about what was
what was inside the box inside the box before opening it?
before opening it?
 Social Neuroscience • 33

unhappy) described themselves (self-judgment) or their favorite teacher

(other-judgment). British researcher Lombardo and colleagues (2009)
had neurotypical adults make mental reflections about themselves or the
Queen. On the self task, participants judged on a scale from 1 (not at all
likely) to 4 (very likely) how likely they themselves would personally agree
with opinion questions (e.g., “How likely are you to think that keeping a
diary is important”). On the other task, the same mentalizing judgments
were made, except this time they were in reference to how likely the Brit-
ish queen would agree with the opinion questions (e.g., “How likely is
the Queen to think that keeping a diary is important”). Vogeley and col-
leagues (2004) asked participants to count the number of balls seen from
the perspective of an avatar in a scene or from their own perspective.
There is considerable overlap of neural areas that process both self- and
other-reflection, but there is also some specificity. A review of imaging
studies on self-reflection provides significant support that cortical mid-
line structures (CMS), a set of regions in the midline of the cortex arching
around the corpus callosum are involved in intrapersonal ToM activities
(self-referential processing). The CMS (constituting the medial prefron-
tal cortex, the anterior, middle, and posterior cingulate cortices; and the
precuneus) are thought to functionally integrate self-related thought and
planning (Northoff et al., 2006). The CMS may mediate the evaluative and
self-reflective aspects of the self, ToM may help understand the mental
states of oneself and others, and the mirror neuron system (MNS) may help
the self simulate the actions of the other to understand goals and inten-
tions. Ramachandran (2009) speculates that mirror neurons may provide
the neurological basis of human self-awareness or intrapersonal ToM. He
hypothesizes that these neurons can not only help simulate other people’s
behavior but can also be turned inward to create meta-representations of
one’s own earlier brain processes. This could be the neural basis of intro-
spection and of the reciprocity of self-awareness and other awareness.

METACOGNITION, EXECUTIVE FUNCTIONS, AND ToM

Neural Foundations for Metacognition and Executive Functions
The study of metacognition emerged at the same time as the study of ToM
(Flavell, 1979), but while researchers investigating ToM focused on its
development in young children, researchers investigating metacognition
focused on school-age children and adolescents. Metacognition is think-
ing about one’s thinking and, hence, is an aspect of intrapersonal cognitive
ToM. Metacognition consists of both knowledge and use of this knowl-
edge to regulate or control one’s cognitive processes. Metacognition,
34 • Westby

as a critical component of executive functions (EFs), is not easily, or

always, separated from EF. And EF has been defined in multiple ways.
Most definitions of EF view it as deliberate, top-down processes involved
in the conscious, goal-directed control of thought, action, and emotion.
Three processes are viewed as the foundations for EF: cognitive flexibility,
inhibitory control, and working memory (Miyake et al., 2000). Metacog-
nitive awareness of these processes is used to regulate and plan behavior.
Some researchers and educators consider planning and regulating behav-
iors as part of EF, while others consider them part of metacognition. EF
requires intrapersonal and interpersonal theory of mind. One must reflect
on one’s knowledge, recognizing one’s knowledge and skills (metacogni-
tion or intrapersonal ToM), and in some situations, one must consider
the impact one’s choices and behaviors will have on others (intrapersonal
ToM). Simultaneously, one must have sufficient EF to inhibit irrelevant,
off-task thoughts or attention to distractions in the environment to
employ ToM (one’s metacognition knowledge; Doherty, 2009).
The frontal lobes are known to be necessary, but not sufficient, for EF
(Alvarez & Emory, 2006). The frontal lobes have multiple connections
to cortical, subcortical, and brain stem sites that likely give rise to higher
level cognitive functions such as inhibition, flexibility of thinking, prob-
lem solving, planning, impulse control, concept formation, and abstract
thinking. Neuroimaging and lesion studies have identified the functions
that are most often associated with the particular regions of the prefron-
tal cortex. These same areas are activated in ToM processing:
• The dorsolateral prefrontal cortex (dlPFC) is associated with
verbal fluency, ability to maintain and shift set, planning,
response inhibition, working memory, organizational skills,
reasoning, problem solving, and abstract thinking (Clark et al.,
2008).
• The anterior cingulate cortex (ACC) is associated with inhibi-
tion of inappropriate responses, decision making, and moti-
vated behaviors (Allman, Hakeem, Erwin, Nimchinsky, & Hof,
2001).
• The orbitofrontal cortex (OFC) plays a key role in impulse
control, maintenance of set, monitoring ongoing behavior
and socially appropriate behaviors. The OFC also has roles in
representing the value of rewards based on sensory stimuli and
evaluating subjective emotional experiences (Rolls & Graben-
horst, 2008).
Until recently, EF was assumed to be a unitary construct with interrelated
components. Although it is recognized that EF encompasses a variety of
 Social Neuroscience • 35

subfunctions (cognitive flexibility, inhibitory control, and working mem-

ory) that work together in the service of goal-directed problem solving, it is
generally assumed that these subfunctions operate in a consistent fashion
across contexts or content domains (Hongwanishkul, Happaney, Lee, &
Zelazo, 2005). In contrast to a domain general view of EF, recent neurosci-
ence research had indicated that EF operates differently in different con-
texts. In light of this research, two types of EF have been distinguished—
“cool” EF involved in tasks requiring cognitive or abstract reasoning and
a “hot” EF involved tasks that have an affective/emotional, motivational,
or incentive/reward (Zelazo  & Cunningham, 2007). Like early research
assessing ToM, which focused on cognitive ToM to the exclusion of
affective ToM, until recently, most studies of EF have focused on tasks
assessing cool (cognitive) EF skills such as the following:
• Attention: selective attention, sustained attention, and inhibit-
ing a response to distractions.
• Goal setting: initiating, planning, problem solving, and strategic
behaviors to reach goals.
• Cognitive flexibility: working memory, attention shifting (stop-
ping one task and starting another), and conceptual transfer
(learning something in one setting and using the knowledge in
a different setting).
Measuring these cognitive aspects of EF has employed tasks that have
no obvious rewards or punishments for completing the activity. In con-
trast, hot (or affective/emotional) EF tasks trigger an effective response
often because of associated rewards or punishments. They are related
to social or communication skills and are not easily measured, because
they depend on a person’s use of current input and his or her interaction
with the environment. Table 2.2 shows types of cold and hot EF tasks.
Neuroimaging studies have confirmed that cool and hot EF tasks
activate different neuroanatomical structures (Rubia, 2011). Cool EF
processes are subsumed primarily by the dorsolateral and ventrolateral
prefrontal cortex. Hot EF processes are subsumed by ventromedial path-
ways connecting mesolimbic reward circuitry, including the amygdala
and striatum, to the ventromedial prefrontal and orbital frontal cortex.
These neuroanatomical foundations are similar to those involved in
cognitive and affective ToM. And, just as there is a dissociation between
cognitive and affective ToM, there is a dissociation between cool and hot
EF. Performance on one type of EF task does not predict performance
on the other type.
Hot and cool EFs are very similar in that they both require
future-oriented cognitive skills; however, hot EFs generally encompass
36 • Westby

Table 2.2 Examples of Cold and Hot EF Tasks

EF cool tasks or assessments Description
Reverse digit span Repeating digits in reverse order
Wisconsin Card Sorting Test Sort cards by color, shape, number rules
quickly and flexibly (Heaton, 1981)
Color word Stroop Name the color of the ink and ignore
the written color name (“red” is printed
in green ink; say “green” rather than
“red”; Stroop, 1935)
Tower of London Moving 3 to 5 different sized beads
following rules measured by time and
number of moves (Shallice, 1982)
EF hot tasks

Delay of gratification Given a cookie and explain choice of

eating one cookie now or if child waits
until examiner returns, will receive 2
cookies.
Gambling Participants select cards from 4 decks,
winning or losing money each time
2 “good” decks, 2 “bad” decks. Scores
based on good choices—bad choices.
By elementary school, students develop
an awareness of which decks will give
them better rewards (Garon, Moore, &
Waschblusch, 2006).

situations that involve higher risks or more stakes and provoke

emotional arousal (Hongwanishkul et  al., 2005). Both cool and hot
EFs have been associated with mental time travel that includes epi-
sodic autobiographical memory and episodic future thinking. Auto-
biographical memory for past experiences involves remembering,
which is different from knowing. I know that I have ridden most of
the rides at Disney World (semantic memory), but I  have an auto-
biographical memory for only some of them, for example, my first
time on the Space Mountain roller coaster—the sounds, darkness,
flashing lights, and dizziness when I got off. Autobiographical mem-
ory involves an awareness of oneself (intrapersonal ToM) in the past
(Fivush, 2011). Similar to autobiographic memory, which allows an
individual to reexperience an event, episodic future thinking allows an
individual to pre-experience an event (Atance & O’Neill, 2001). Epi-
sodic future thinking (or mental time travel) involves intrapersonal
ToM because it requires that one imagine oneself in the future; it also
 Social Neuroscience • 37

involves developing a plan that takes into account one’s specific situ-
ation; hence, it involves EFs. Autobiographical past memory and epi-
sodic future thinking skills emerge around age 4, the same time that
children become able to think about the perceptions and beliefs of
others (Atance & O’Neill, 2005).
Neuroimaging has revealed that remembering and simulating the
future depend on common neural substrates; the core network acti-
vated in both cases includes the hippocampus, the posterior cingu-
late gyrus, the medial frontal cortices, and the TPJ (inferior parietal
lobule and lateral temporal cortices; Botzung, Denkova, & Manning,
2008; Mullally & Maguire, 2013). It is possible to form new seman-
tic memories, but not episodic memories, without the hippocampus.
Activity in this network is greater during simulation of future events
than during remembering. Remembering past events and simulating
future ones activates overlapping regions of the core network of brain
structures, but past and future time travel is associated with a dis-
tinct subsystem within the network. For example, extensive regions of
the medial prefrontal cortex, the parietal lobe, and the anterior por-
tion of the hippocampus are activated during the imagining of future
events, but not during the retrieval of memories. On the other hand,
remembering, but not imagining, leads to activation of parts of the
visual cortex, likely reflecting the imagery associated with memory
retrieval.
Individuals who have deficits in ToM abilities—as is the case with
ASD—are likely to show similar deficits in autobiographical memory
and episodic future thinking (Powell & Jordan, 1993; Terrett et al., 2013).
Deficits in future thinking may explain some of the repetitive and ste-
reotyped behaviors and the lack of behavioral flexibility seen in persons
with ASD. It is plausible that such inflexibility stems from underlying
difficulties with planning and future thinking (Suddendorf & Corballis,
1997). These episodic memory deficits may be due to the inability to
form a relationship between one’s past and present self and to dissociate
from one’s own current state.

NEUROCHEMISTRY
Genetic Factors Influencing Neurochemistry
Neuroanatomical models for ToM cannot fully explain how various
pathologies that present with differing neurobiological abnormalities
such as autism or reactive attachment disorder exhibit similar ToM
dysfunctions or how persons with a single disease such as Parkinson’s
38 • Westby

disease exhibit differing profiles of ToM impairments. To explain these

variations, Abu-Akel and Shamay-Tsoory (2011) suggest consider-
ing the neurochemical basis of ToM. There is some evidence that the
dopaminergic-serotonergic (DS) system has a role in ToM. This is based
on the observations that ToM dysfunctions are frequent consequences of
disorders that are associated with deficits in the DS system such as autism
(Chugani, 2012; Folsom  & Fatemi, 2011) and schizophrenia (Bosia
et al., 2010) and that the DS system innervates the PFC, the TPJ, and the
ACC, regions critical to ToM. Genetic variations influence production
and metabolism of neurotransmitters, such as dopamine, which in turn,
affect ToM performance. Furthermore, there exists a rather complex
interaction of genotype and environment related to differential suscep-
tibility and biological sensitivity to context—the differential-sensitivity
hypothesis (Pluess, Stevens, & Belsky, 2013). This hypothesis states that
persons differ in their susceptibility to environmental influence—both
the adverse effects of unsupportive contextual conditions and beneficial
effects of supportive ones. Several genotypes are known to affect pro-
duction or metabolism of neurotransmitters that have been associated
with variations in social skills, aggression, and ToM.
Monoamine oxidases (MAOs) are enzymes that are involved in the
breakdown or inactivation of neurotransmitters such as serotonin and
dopamine and are, therefore, capable of influencing feelings, mood, and
behavior of individuals. The monoamine oxidase A  gene (MAOA) is
involved in neural circuitry between the ventromedial frontal cortex and
the amygdala, regions implicated in social behavior, theory of mind, and
empathy. The low-activity MAOA genotype has been associated with
antisocial behavior, particularly in persons who have experienced abuse
during childhood (Fergusson, Boden, Howood, Miller,  & Kennedy,
2011). Maltreated children with genotypes causing high levels of
MAOA are less likely to develop antisocial behavior (Caspi et al., 2002).
An interesting finding of this study was that those more vulnerable to
the adverse effects of maltreatment actually scored lowest in antiso-
cial behavior when not exposed to maltreatment, suggesting perhaps
greater plasticity rather than just greater vulnerability. Other research
has supported this hypothesis. For example, Kim-Cohen and colleagues
(2006) found that boys with the low-MAOA-activity variant were rated
by mothers and teachers as having mental health problems, and spe-
cifically attention-deficit/hyperactivity disorder symptoms, if they had
been victims of abuse, but fewer problems if they had not, compared
with the high-MAOA activity genotype. Foley and colleagues (2004) also
observed that twin boys with the low-activity allele were more likely to
be diagnosed with conduct disorder if they were exposed to higher levels
 Social Neuroscience • 39

of childhood adversity and less likely if exposed to lower levels of adver-

sity compared with boys with the high-MAOA-activity allele. Figure 2.3
shows the effects of genotype-environment interactions on social skills
and ToM.
A similar pattern has been found between the dopamine receptor
DRD4 gene and environment. The dopamine receptor DRD4 gene vari-
ation predicts preschoolers’ developing theory of mind (Lackner, Sab-
bagh, Hallinan, Liu, & Holden, 2012) and it moderates infants sensitivity
to maternal affective communications (Gervai et al., 2007). In supportive
environments, neurotypical children with the short allele variant of the
DRD4 gene perform better on ToM tasks than children with the long
allele variant. However, infants with the short variant of the DRD4 gene
are more affected by disrupted maternal communication, having more
disorganized attachments that could potentially later result in lower ToM.
The long 7-repeat allele of DRD4 has been associated with hyperac-
tivity. But several studies have suggested that parenting may affect the
cognitive development of children with the 7-repeat allele of DRD4. Par-
enting that has maternal sensitivity, mindfulness, and autonomy-support
at 15 months was found to alter children’s executive functions at 18 to
20 months (Bakermans-Kranenburg & Van IJzendoorn, 2006). Children
with poorer quality parenting exhibited more hyperactivity—they were
more impulsive and sensation seeking than were those with higher qual-
ity parenting. Yet 4-year-old children with the long DRD4 allele who
experienced higher quality parenting actually exhibited better effort-
ful control than did children who did not have this allele (Sheese, Voel-
ker, Rothbart, & Posner, 2007). Children with the DRD4 long allele and
secure attachment with their mothers exhibited more prosocial, altruistic

High
2 alleles

1 allele
Social Skills
& ToM

Low
Aversive Supportive
Environment Environment

Figure 2.3 Effects of genotype–environment interactions on social skills and ToM

40 • Westby

behavior than did children with the DRD4 long allele and insecure attach-
ment. Children with the DRD4 short allele exhibited no difference in
altruism regardless of their attachment (Bakermans-Kranenburg & Van
IJzendoorn, 2011).
Oxytocin plays a role in how we perceive our own and other’s emo-
tional states. Oxytocin increases sociability and emotional empathy
(Hurlemann et al., 2010). In contrast to persons with one or two copies
of the G allele for the oxytocin receptor gene (OXTR), persons with one
or two copies of the A allele have exhibited lower dispositional empa-
thy as measured by their ratings on the Interpersonal Reactivity Index
(Davis, 1983) and lower behavioral empathy as measured by their scores
on “Reading the Mind in the Eyes” test that required them to interpret
emotions from eyes (Rodrigues, Saslow, Garcia, Johna,  & Keltnercet,
2009). Variants of the OXTR gene have been associated with autism
(Hammock et al., 2012; Wermter et al., 2010).

Environmental/Genetic Factor Interactions

Environmental factors can affect neuroanatomical development and
neurochemical functioning. Children who have been reared in institu-
tions in their early years have significantly smaller cortical gray matter
volume (Sheridan, Fox, Zeanah, McLaughlin,  & Nelson, 2012). Mal-
treated children have been found to have smaller brain volumes in the
OFC, the area critically important in affective ToM (de Brito et al., 2013;
Hanson et al., 2010), as well as in the middle temporal gyrus (de Brito
et al. 2013), which is implicated in autobiographical memory, emotion
regulation, and decision making. Many of the brain changes in institu-
tionalized and maltreated children have been found to be related to the
brain’s response to stress. Stress produces long-lasting alternations to the
hypothalamic–pituitary–adrenal (HPA) axis. When persons experience
ongoing toxic stress, the adrenals continue to produce high levels of cor-
tisol. This long-term exposure to cortisol results in reduced dendritic
growth and atrophy of neurons in the hippocampus, dendritic shorten-
ing in the medial prefrontal cortex, increased dendritic growth, and neu-
ronal hypertrophy in the amygdala. These brain changes result in poorer
memory and ToM, while at the same time more intense fear and anger
responses. The FKBP5 gene is involved in regulation of the HPA axis.
The HPA axis is less regulated in children with several allele variations of
the FKBP5 gene who have experienced early abuse or neglect, and as a
result such children are exposed to higher cortisol levels associated with
stress (White, Bogdan, Fisher, Munoz, & Hariri, 2012). Variations in the
FKBP5 gene alleles contribute to risk or resilience in response to difficult
environments (Gillespie, Phifer, Bradley, & Ressler, 2009).
 Social Neuroscience • 41

Recent work in developmental neuroscience and epigenetics is offer-

ing suggestions for how early-life experiences and environmental influ-
ences interact directly with genes in the developing brain. Studies are
showing how epigenetic mechanisms that regulate gene activity in the
central nervous system are modified by experiences, particularly those
occurring within the context of caregiving (Roth & Sweatt, 2011). Envi-
ronmental experiences can result in special chemicals called tags (epi-
genomes) becoming attached to our genes, and, depending on the nature
of these tags, specific genes can either be silenced (prevented from being
expressed as protein) or pushed to become more active. These epigenetic
changes may last through cell divisions for the duration of the cell’s life
and may be inherited for multiple generations. When these epigenomic
chemicals become attached to genes controlling neurotransmitters, ToM
abilities can be disrupted. These epigenetic changes in combination with
particular genotypes may explain why some children reared in abusive
or neglectful backgrounds appear to develop relatively well, while others
exhibit deficits in theory of mind and social skills and are at greater risk
for a variety of health problems. Children with the short variant of the
DRD4 dopamine receptor gene, the low-activity MAOA gene, the AA or
AG allele of the oxytocin gene, or variants of the FKBP5 gene are likely
to have significant social and behavioral difficulties if they experience
maltreatment in early childhood but not if they are reared in healthy,
supportive environments.

CULTURAL NEUROSCIENCE
Cultural neuroscience is the study of how cultural values, practices,
and beliefs shape and are shaped by the mind, brain, and genes. The
first issue of Culture and Neuroscience was published in 2013. ToM is
a primary factor that separates humans from other primates. Human
social interactions require ToM, but people in different cultures have
differing theories regarding what the mind is (Luhrmann, 2011), and
they hold differing views of their relationships with one another. Inter-
personal and intrapersonal ToM abilities develop in a relatively sim-
ilar time frame across cultures, but there are some variations in just
how these abilities are manifested. For example, children in the United
States develop understanding that people can have different beliefs or
opinions before an understanding that people can be knowledgeable or
ignorant. This order of development is reversed in Chinese and Iranian
children (Shahaeian, Peterson, Slaughter, & Wellman, 2011). Wellman,
Fang, Liu, Zhu, and Liu (2006) suggested that some cultures, such as the
42 • Westby

Chinese, value knowing and children acquiring practical knowledge,

whereas other cultures, such as the United States, give more emphasis
to truth, falsity, and differences in belief. Because of these different val-
ues or emphases, knowing may be more salient and important in some
cultures and thinking and believing may be more salient and important
in other cultures.
Cultural neuroscience is interested in how these and other differ-
ences in values might be reflected in differences in brain functioning.
Cultures have often been contrasted in terms of value systems oriented
either to individualism or to collectivism. Individualist cultures, such
as those of the United States and Western Europe, view the self as
autonomous from others; collectivist cultures, such as China, Korea,
and Japan, view the self as connected to or defined by others or the
social situation (Triandis, 1995). fMRI studies of persons from indi-
vidualistic and collective cultures performing ToM tasks show many
similarities in the areas of the brain that are activated, but there are
some variations that could be explained by these differences in cultural
orientations. Particularly, there are neural differences when persons
from individualistic and collective cultures make judgments about
themselves. Researchers have suggested this may be because persons
from collective cultures have a reduced sense of self–other distinction
than persons from individualistic cultures do (Chaio et al., 2009; Sul,
Choi,  & Kang, 2012). When processing emotional expressions, per-
sons from collective cultures show greater amygdala response than do
persons from individualistic cultures. At this time, the clinical signifi-
cance of these differences in neural functioning among cultural groups
is uncertain.

DISCUSSION QUESTIONS
1. Describe the different dimensions of ToM and their neuroana-
tomical foundations.
2. How can the different dimensions of ToM be assessed?
3. Explain why some children may be less affected by poor envi-
ronments than other children.
4. Discuss the relationships among metacognition, EF, and ToM.
5. How are cognitive and affective ToM related to hot and cold EF
tasks?
6. What behavioral precursors should be observed in children be-
fore they pass the typical ToM tasks?
7. Describe the neural components of facial processing.
 Social Neuroscience • 43

INSTRUCTIONAL RESOURCES
Websites
Child Maltreatment and Brain Consequences: www.youtube.com/watch?v=r6_
nindqsTs
Epigenetics: www.pbs.org/wgbh/nova/body/epigenetics.html
Nova Science Now Mirror Neurons: www.youtube.com/watch?v=Xmx1qPyo8Ks
TED Talks Epigenetics: www.youtube.com/watch?v=JTBg6hqeuTg
TED Talks Rebecca Sax, How We Read Each Other’s Minds: www.youtube.
com/watch?v=GOCUH7TxHRI
TED Talks: VS Ramachandran: The Neurons That Shaped Civilization: www.
youtube.com/watch?v=t0pwKzTRG5E
The Human Spark DVD: www.pbs.org/wnet/humanspark/episodes/program-
three-brain-matters/video-full-episode/418/
Simon Baron-Cohen, Zero Degrees of Empathy: www.youtube.com/
watch?v=Aq_nCTGSfWE

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 3
SOCIALEMOTIONAL DEVELOPMENT
ASSOCIATED WITH SOCIAL COMMUNICATION
Deborah A. Hwa-Froelich

[E]motions represent the dynamic processes created within the socially

influenced, value-appraising processes of the brain. . . . Emotional pro-
cessing prepares the brain and rest of the body for action.
—Siegel (1999, pp. 123–124)

From the beginning of life, emotion constitutes both the process and the
content of communication between infant and caregiver . . . parents use
words to talk about feeling and direct a shared attention to the infant’s
state of mind. The parents may state directly that the baby is feeling sad
or happy or scared, giving the infant the interactive verbal experience of
being able both to identify and to share an emotional experience.
—Siegel (1999, p. 270)

LEARNING OBJECTIVES
Readers will
1. Be able to define attachment, attunement, and attachment rela-
tionships.
2. Be able to describe the development of emotion regulation and
self-regulation.
3. Gain knowledge about how cultural differences in values and
beliefs may affect social emotional development.

50
 Social-Emotional Development • 51

4. Learn how environmental and socioeconomic variables may

influence social emotional development.
5. Be able to describe how different cultural caregiving habits may
influence children’s social emotional development.
Anthony was referred to the special education cooperative by his grand-
parents, Mr. and Mrs. Lopez. They were concerned that he was not talk-
ing at the age of 3. Mr. and Mrs. Lopez were business leaders in the small
community and often provided child care for their two grandchildren
during the day until Mrs.  Barber, Anthony’s mother, was able to pick
them up after work. Mrs. Barber had siblings living in the area who also
provided support for her and her children. During an interview with
the speech-language pathologist (SLP), Mrs. Barber shared that she and
her husband were alcoholics but recently she had stopped drinking and
was attending Alcoholics Anonymous (AA). Her husband continued to
drink, and for this reason, she was seeking a divorce and full custody of
her children. She reported that she stopped drinking when she learned
that she was pregnant with Anthony but had struggled to stay sober
during the first 2 years of Anthony’s life. After Anthony turned 2, she
decided to stop drinking and has been sober for the past year.
As part of an ecological assessment, the early childhood team col-
lected medical reports and conducted several assessments. Anthony’s
pediatrician reported that Anthony did not show characteristics of
Fetal Alcohol Syndrome. Prior to administration of behavioral meas-
ures, Anthony passed a hearing screening. The SLP and the school psy-
chologist interviewed Mrs.  Barber, Anthony’s mother, and observed
Anthony following his brother’s lead and taking turns during pretend
play. A  behavioral assessment took place at the early childhood pre-
school with the early childhood special educator (ECSE), SLP, mother
and grandmother. A play-based assessment and the Preschool Language
Scale-4 (PLS-4; Zimmerman, Steiner, & Pond, 2002) were administered.
Anthony displayed strengths in understanding language, attention,
solving problems, and demonstrating complex thematic play without
language expression. He did not express himself during play or testing
which affected measures of memory, emotional expression, sense of self,
emotional themes and social interactions. Although Anthony scored
within normal range on the receptive language portion of the PLS-4, he
did not respond during the expressive language section. He also dem-
onstrated freezing behaviors when voice or sound levels increased in
volume. In conclusion, Anthony was delayed in socio-emotional and
communication development and demonstrated some anxious and
insecure behaviors.
52 • Hwa-Froelich

Anthony exhibited social, emotional, and expressive language delays

that were influenced by his exposure to negative experiences such as his
parents’ alcohol abuse and possibly contentious disagreements during
his parents’ marriage, as well as the process of separation and divorce.
Loud voices or noises resulted in a fight or flight response of freezing
behaviors often observed in children who have experienced traumatic
events or children who are insecurely attached to their caregivers. To
help Anthony overcome his fears and insecurity, he needed to repair his
relationship with his mother and build trusting relationships with other
adults such as his grandparents.
When infants are born, they are completely dependent on the care
of others to provide safety, nurturance, affection, and stimulation. It is
because of this dependency to meet their needs that infants need and
seek a social and emotional connection with their caregivers. While it
is outside the scope of this chapter to describe in rich detail all aspects
of social and emotional development, the purpose of this chapter is to
summarize the stages of socio-emotional and regulation development
(attachment, attunement, empathy, interpersonal regulation to intraper-
sonal regulation, self-regulation, and inhibition), and relate these devel-
opmental areas to social communication development and disorders.

ATTACHMENT AND ATTUNEMENT

Over time, infants develop an emotionally based relationship or attach-
ment to persons who provide for their needs by interpreting their non-
verbal behaviors and verbal cries for help and through the caregivers’
attempts to make infants feel safe, secure, and satisfied (Ainsworth,
1973; Bowlby, 1969). Attachment develops during infants’ early years
to create an enduring emotional relationship between the infant and a
nurturing adult caregiver(s) who provides comfort and a sense of safety
by providing routinized care in a predictable environment. Greenspan
(1985) describes the stages of this socio-emotional development as (a)
falling in love with the caregiver around 3 to 4 months of age, (b) know-
ing the caregiver is permanent at 9 months, and (c) feeling securely
attached by 2 years of age. Over time, infants develop a mental represen-
tation of their attachment relationship and infants refer to these mental
representations as a “secure base” or a source of comfort during times
of separation or distress (Siegel, 1999, p. 71). For example, during object
permanence the infant has a mental representation of his or her mother
or primary caregiver and calls out when this person is not in sight. By
 Social-Emotional Development • 53

1 year of age when the infant seeks comfort or interaction, the infant
anticipates the caregivers’ responses and calms down when the caregiver
approaches (Wilson, 2012). From the foundation of this secure attached
relationship, the infant views the world as predictable and manageable
which allows them to venture out to explore the environment, interact-
ing with novel objects, events, and other persons. This parent–infant
relationship also provides a framework for later relationships with oth-
ers (Eagle, 1995; Siegel, 1999). Through the infinite interactions infants
have with their caregivers and the nurturing attuned effect of caregiv-
ers’ responses on infants’ physiological state, caregivers influence how
infants view the world and how they interact with their environment.
Small and large differences in these parent–infant interactions can result
in uniquely different socio-emotional developmental outcomes (Wilson,
2012). These variations are in alignment with dynamic systems theory
as described in Chapter 1.
When caregivers respond consistently, appropriately, and contin-
gently to their infants’ cries for comfort or assistance over time, a secure
attachment is more likely to develop. This requires sensitivity, in that the
caregiver must be able to read infants’ cues to figure out what is caus-
ing their distress as well as which kinds of responses will calm them. As
caregivers are consistently successful in calming an infant or attuned
to the infant, their infants will prefer and seek assistance from them
as a means to resolve their distressed state and achieve a state of calm
(Greenspan, 1985; Wilson, 2012). Through attunement a secure attach-
ment develops, and from this foundation, infants feel safe enough to
explore because they have learned that their caregiver will assist or care
for them if they become scared or hurt. If during their exploration of
the world, infants are uncertain, they may interact with their caregiver
through eye contact or physically moving closer to the caregiver to
observe the caregiver’s response to the object or situation. If the care-
giver smiles, comments that it is safe, or models how to interact with the
novel object, event, or person, the infant borrows the calm emotional
state from the caregiver to regulate his or her initial uncertainty or fear.
Only when infants feel safe can they explore their environment so that
learning can take place (Greenspan, 1985; Wilson, 2012).
Over time, infants develop a mental representation not only of the
caregiver but also of the kind of relationship they expect with their care-
giver. If the majority of the interactions result in attunement, in that the
caregiver is successful in comforting, calming, and meeting the infant’s
needs, then the infant expects the caregiver to be emotionally and physi-
cally available and interact in positive and supportive ways. This type of
caregiver–child relationship is often judged to be a secure attachment
54 • Hwa-Froelich

(Bernier, Carlson,  & Whipple, 2010; Stams, Juffer,  & Van IJzensoorn,
2002). As Samantha Wilson (2012) described,

caregivers are not perfectly accurate in deciphering their children’s

needs at all times, nor should they be expected to be; there are many
expectable (and appropriate) missteps in dyadic communication.
These missteps, in and of themselves, are not inherently problem-
atic, and in fact provide the child with mild, tolerable frustrations
that allow him to increase regulatory coping. In most cases, a com-
petent (i.e., ‘good enough’) caregiver recognizes the miscues and
works to repair them quickly. (p. 62)

In other words, it is through more consistent and competent social

interactions that children feel they have a strong, secure foundation
from which to explore the world allowing them to better manage and/or
predict outcomes. It also helps children to view interactions with other
people as positive and enjoyable promoting future relationships with
peers and other adults. Through attuned caregiving, children receive
face-to-face contact with their caregivers, enabling them to process
facial expressions, tone of voice, and body postures (nurturing, flexible
versus stiff and distant postures). This type of interaction helps children
also develop skills to process, determine the value of, and interpret emo-
tions of others, which are discussed in Chapter 4.
What happens when caregivers are not successful at reading their
infants’ cues, respond inconsistently, negatively, or inappropriately to
their infants’ cries for comfort or safety? Infants are born expecting
and dependent upon developmentally appropriate care and stimu-
lation (Fox, Levitt, & Nelson, 2010). Thus, when the majority of the
infant–caregiver interactions are inappropriate, inconsistent, and/
or negative, then infants may feel insecure, unsafe, or unsure about
their safety even when the caregiver is present (Cicchetti & Toth, 1995;
Siegel, 1999). They perceive the environment as unpredictable, cha-
otic, overwhelming, and/or unsafe. In these kinds of cases, children
demonstrate a type of insecure attachment relationship. Typically,
three different types of insecure attachment have been described in
the literature (Siegel, 1999; Wilson, 2012). An avoidant type of inse-
cure attachment is demonstrated when the child avoids the caregiver,
does not appear to share or exchange emotions with the caregiver,
and does not show stress behaviors on separation, novel, or fearful
situations. The parents may appear emotionally unavailable, to have
low affect, insensitive to their child’s needs, or developmentally inap-
propriate. A  caregiver–child relationship is judged to be a resistant
 Social-Emotional Development • 55

insecure attachment when the child tends to inhibit play or explora-

tion and/or appears to be ambivalent when stressed. For example, a
child continues to cry regardless of whether the parent is present or
not or s/he appears to be focused on his or her distress. The parent or
parents are inconsistently available, sensitive, or successful and thus
seem to be unpredictable. Finally, perhaps the most impaired attach-
ment relationship that is most often associated with psychopathology
is a disorganized attachment (Wilson, 2012). Children who demon-
strate a disorganized type of attachment may display contradictory
behaviors such as seeking caregiver proximity and comfort while try-
ing to strike the caregiver, an inconsistent approach pattern in which
the child walks toward the parent and then stops or backs up or has
uninhibited, impulsive, frantic behavior with little to no emotional
connection to the caregiver during a free-play situation (Siegel, 1999;
Wilson, 2012). Parents may be abusive, may be emotionally frighten-
ing, or display sudden unpredictable shifts in their mental states, such
as rapid shifts from happy and loving to sad, distant, or angry.
In insecure attachment relationships, a child is unable to cope with
stress either because the parent is the cause of the stress or because the
child experienced such negative early experiences that when a stress-
ful event occurs, the child has not developed coping behaviors or a
secure relationship with the caregiver or caregivers. Instead of having a
caregiver help children cope, a secure attachment relationship represen-
tation to refer to or coping behaviors to employ for stressful events, chil-
dren may develop reflexive behavioral patterns such as a fight or flight
response to all stressful stimuli. This fight-or-flight reflex is associated
with the primitive part of the brain, the limbic system, and serves as a
primitive, unconscious, survival behavior (refer to Chapter 2). As Siegel
(1999) describes, “emotions are primarily nonconscious mental pro-
cesses. In their essence they create a readiness for action, . . . disposing
us to behave in particular ways within the environment” (p. 132). When
stressed, infants may activate the sympathetic-adrenomedullary (SAM)
system responsible for activation of the fight-or-flight response (Lad-
age, 2009). Long-term exposure to stress may result in an overactive
hypothalamic-pituitary-adrenal (HPA) stress axis resulting in higher
than normal levels of the growth hormone, cortisol. The lasting effect of
high cortisol levels is psycho-social short stature (growth disorder asso-
ciated with stress or emotional deprivation), as well as lower cognitive
and motor performance scores (Ladage, 2009; Mason & Narad, 2005,
p. 5). The limbic–hypothalamic–pituitary–adrenocortical axis may also
be affected which is associated with the production of glucorticoids.
This hormone has a negative impact on processes involved in learning
56 • Hwa-Froelich

and memory (for a review see Gunnar & Quevedo, 2007). Children who
are exposed to adverse care for long periods may maintain high stress
levels resulting in over-pruning of synaptic connections and less than
optimal neurological development such as in the right hemisphere and
frontal lobes. These neurological structures are important for process-
ing emotions and behaviors, attachment, empathy, regulation of affect,
problem solving, and cognitive flexibility (Fox et al., 2010; Gunnar &
Quevedo, 2007; Nelson, 2007; Sánchez  & Pollak, 2009; Schore, 2001;
Siegel, 1999). Emotions may be psychologically separated from con-
sciousness or be repressed, and therefore, these emotions may not be
expressed verbally. In some cases children may not appraise or reflect
on these emotions (Saarni, 1999). Children who have a fight-or-flight
response often display heightened vigilance, flighty, active, aggressive,
passive withdrawal, or freezing behaviors in response to stimuli they
perceive as a threat. With this kind of response, learning becomes sec-
ondary to survival and these learning patterns persist unless children
experience significant changes in the maltreating environment. Over-
all, when children endure high levels of stress for long periods, their
physical, social, emotional, cognitive, and overall learning are adversely
affected. Because of their negative relational experiences, children who
are insecurely attached tend to have more difficulty regulating and
understanding their own and others’ emotions, which may negatively
affect their social competence.
Regardless of culturally diverse parenting practices, similar estimates
of secure and insecure attachment have been reported across countries
(Van IJzendoorn & Sagi-Schwartz, 2008). For example, the US Depart-
ment of Health and Human Services (DHHS) estimates that approxi-
mately 65% of infants have a secure attachment relationship and 35%
have an insecure attachment (DHHS, 1991). Emery, Paquette, and Bigras
(2008) reported approximately 59% of 138 Canadian teen mothers had
a secure attachment with their infants. As far as insecure attachment
relationships, approximately 20% of infant attachment relationships are
avoidant, and 10% to 15% were reported to be ambivalent in the United
States (DHHS, 1991). Similarly, Taylor, Marshall, Mann, and Goldberg
(2012) reported a rate of 28% insecure attachment in cases with medi-
cally unexplained symptoms across 10 general medicine practices in the
United Kingdom, and Emery and colleagues (2008) reported a rate of
9% avoidant and 5% resistant or ambivalent attachment in Canadian
parent–infant samples (Taylor et al., 2012). Approximately 10% to
15% of US caregiver–infant relationships and 26% of Canadian teen
mother–infant relationships were reported to be disorganized (Emery
et al., 2008; DHHS, 1991).
 Social-Emotional Development • 57

TRANSITION FROM INTERPERSONAL REGULATION TO

INTRAPERSONAL EMOTION REGULATION
Before emotion regulation can be discussed, it is important to define
what emotion is and outline the stages of emotional development. Holo-
dynski (2013) reviewed the historical and cultural literature on emotion
and emotional development and defined emotions as

a functional psychological system involving the synchronic inter-

play of general components and serving to regulate actions within
the macrostructure of activity in line with a person’s motives. . . .
An emotion is made up of four components: appraisal, expression,
body regulation, and subjective feeling. (p. 11)

Emotions are important intrapersonally and interpersonally. Knowing

how one feels about objects or events helps one determine an individu-
ally appropriate response. During interpersonal interactions, emotions
help each participant by adding information to the interchange. Accurate
interpersonal interpretation of other people’s emotions helps to guide
one’s behavior during the interaction (Denham, 1998). Denham (1998)
describes emotions as a process during which each individual orients to
a change in their environment or in themselves that alerts the Autonomic
Nervous System (ANS) and the lower primitive brain. Orientation and
alertness moves to an appraisal process during which the stimulus is
judged along a continuum of intensity, familiarity, and expectedness and
is compared with past memories of similar stimuli or situations. If the
appraisal does not match internal expectations of the stimulus or situ-
ation, then the infant becomes aroused by this dissonance and is more
alert and energized (Siegel, 1999). If the stimulus is appraised as positive
or interesting, the infant may move from a calm state to a heightened
arousal or alertness. However, if the stimulus triggers a negative emotion
or uncertainty, the infant may move to a heightened stress reaction for
which the caregiver is needed to help the infant achieve a state of calm.
These changes in mental states may involve lower level emotions such
as fear, frustration, surprise, or joy (Siegel, 1999). As the infant develops
and has more experiences mediated by a caring adult, changes in the
environment and the ANS result in sympathetic and parasympathetic
physiological changes associated with stress, excitement, or calm, such as
increased/decreased blood pressure, respiration, and heart rate (Siegel,
1999). Changes in the environment and the ANS also trigger cognitive
appraisal of the stimulus or stimuli such as conscious tendencies to behave
in certain ways (crying, clinging, increased movement, exploration;
58 • Hwa-Froelich

Denham, 1998). Over time, in a secure attachment relationship, infants

eventually remember and learn which stimuli are safe or how to
seek and read their caregivers’ cues as to whether they should engage
with the stimulus. They also learn coping strategies to achieve a calmer
state when confronted with situations that are stressful or exciting or in
the absence of the caregiver (sucking on thumb, cuddling with a blanket).
Emotions provide meaning and motivation for activity and partici-
pation, help organize the brain, and are linked to one’s memories. As
explained in Chapter 2, the right and left hemispheres are differentiated
in emotion processing. The right tends to process nonverbal communica-
tion and positive emotions while the left tends to process verbal commu-
nication and negative emotions (Siegel, 1999). Emotional understanding
of self and others helps individuals understand and connect with others
(Siegel, 1999). It is through socio-emotional interactions with caregiv-
ers that children learn about their emotions and learn to regulate them
independently from their caregivers. The more secure and attuned the
attachment relationship, the more caregivers help infants achieve a calm,
positive emotional state when they experience physiological stressors such
as hunger, pain, fear, or discomfort. Caregivers model through face-to-face
interactions, a calm, loving face and tone of voice as well as nurturing pos-
tures and touch. At the same time, nurturing caregivers provide labels for
the infant’s mental states and emotions to help the infant begin to identify
their own internal states. In other words, the infant borrows the emo-
tional and mental states of their caregivers to help regulate their stress and
negative emotions (Bronson, 2000; Legerstee, 2005; Schore, 2001, Sroufe,
1997). Table 3.1 provides the sequence of emotional development.
As the child begins to encounter novel objects, events, and people,
he or she emotionally engages with his or her caregiver to check the
caregiver’s emotional state or opinion regarding the exploration of
these uncertain contexts (Mundy  & Sigman, 2006). From these inter-
changes, the child learns how to interpret different emotions from facial
expressions and vocal tones, which objects or events should be avoided
or treated with caution and which ones are safe, and how to minimize
their stress or uncertainty in stressful situations (Legerstee, 2005; Moses,
Baldwin, Rosicky,  & Tidbell, 2001). As children and caregivers inter-
act and experience joint attention, children gain knowledge about their
internal feelings, about how their caregiver calms them, about how to
deal with stressful events, and about how other people feel and act. At
the same time, children are acquiring a symbol system to associate labels
to feelings, mental states, and beliefs.
There are differences in frequency of different emotions displayed
and expressed. Denham (1998) reviewed research in which toddlers
 Social-Emotional Development • 59

Table 3.1 Development of Emotions

0–3 months Aware of self-interest in world
5 months Aware/responds to familiar others
7 months Discriminates between facial expres-
sions
9 months Intentionality
13 months Complex emotions (love, curiosity,
protest)
18 months Shows joy, fear, and anger
2 years Mental models of feelings, can link
emotions to situations, can deceive and
understand deception
3 years Emotional talking, can understand
people may feel differently about same
event
4 years Bridges emotion to beliefs to causal-
ity, time, space; shows empathy toward
peers
5–6 years Knows beliefs can result in specific
emotions, can predict emotions
7–8 years Understands a person can feel several
emotions at the same time, morally bad
behavior results in negative emotions
and morally praiseworthy acts result in
positive emotions

Source:
Denham (1998); Holodynski (2013); Pons, Harris, and de Rosnay (2004); and Timler
(2003).

display more happy and angry emotions than sad, painful, or distressful
ones. By preschool age, children’s negative emotions tend to decrease
in frequency. During the first 3  years, children consistently demon-
strate the emotions of anger, fearfulness, interest, and joy. Denham also
reported in her literature review that boys tended to express more anger,
less shame, and less pride, whereas girls tended to express more sadness,
shame, and pride (for a review, see Denham, 1998). Gender differences
may be influenced by parents’ differentiated interactions with their sons
and daughters. Carpendale and Lewis (2006) reviewed studies in which
parents expressed more emotional words to their daughters than to
their sons, which, over time, was associated with girls expressing more
emotion words than did boys.
As children mature, they increase their understanding and expres-
sion of emotions. As Denham (1998) described,
60 • Hwa-Froelich

over 75% of 3-year-old children use terms for feeling good, happy,
sad, afraid, angry, loving, mean, and surprised (Ridgeway  &
Kuczaj, 1985). By the end of the preschool period, over 75% of
6-year-olds also use terms for feeling comfortable, excited, upset,
glad, unhappy, relaxed, bored, lonely, annoyed, disappointed, shy,
pleased, worried, calm, embarrassed, hating, nervous, and cheerful
(Ridgeway & Kucaj, 1985). (p. 77)

The secure relationship, socio-emotional knowledge, and language

development work together to enable the child to regulate negative emo-
tions, develop empathy (affective empathy as described by Westby in
Chapter 2), think and problem solve in language or develop what Vygot-
sky (1934/1986) termed internal speech. When caregivers accurately
interpret their children’s emotions and explain the emotions of others,
these children not only learn the emotional labels linked to emotional
events, they learn how emotions cause people to act in certain ways and
that certain kinds of events cause people to feel particular emotions (for
a review see Cole, Armstrong, & Pemberton, 2010; Denham, 1998). This
social knowledge and understanding builds their social cognition and
understanding about the world and people as well as helps them predict
and plan for future interactions (discussed in Chapter 4). In other words,
these experiences help the child gradually move from an interpersonal
(caregiver–child) system of emotion regulation, that is, depending on
the caregiver to help them regulate stressful situations, to an intraper-
sonal regulation system where children begin to independently calm
themselves and eventually learn to care for others (Holodynski, 2013).
Understanding of emotions is also affected by parenting strategies.
When parents express more anger, tension, or sadness, their children
demonstrate more anger, confusion, or pain (Denham, 1998). In addi-
tion, when caregivers arbitrarily set limits and consistently enforce those
limits, they tend to have children who have less understanding of emo-
tion, whereas caregivers who were inconsistent in setting limits and
enforcement had children with more emotion understanding. This was
not true for the caregivers who were more indulgent and set fewer limits.
These indulgent caregivers tended to have children with less emotion
understanding. In other words, families whose discipline is less arbitrary,
more empathetic, and rational may use a situation-by-situation approach
considering negative and positive emotional experiences. This approach
allows children to more effectively learn about emotions (Denham,
1998).
Because children’s knowledge of self and others’ emotions is
dependent on their caregivers’ view of the world, when caregivers are
 Social-Emotional Development • 61

inaccurate in interpreting their children’s emotions or inappropriate

in social interactions with their children, their children may demon-
strate delays or different patterns of development and expression of
emotions and affective ToM. If parents are inaccurate in reading and
labeling their children’s emotions, their children may have difficulty
identifying their own feelings as well as the feelings of others. Children
who are insecurely attached may not know how they feel, or they may
mask their feelings to other people (Siegel, 1999). There may be a dis-
connect between the right and left hemispheres when nonverbal and
verbal expressions of emotions contradict each other. For example in
the case of children with an avoidant attachment, they may have par-
ents who are rejecting or uninvolved. These children may avoid social
interactions and reduce emotional expression to avoid their frustra-
tion of interacting with an unavailable or negative parent. As adults,
they may suppress their own emotions and prefer to not emotionally
engage with others (Siegel, 1999). In the case of an ambivalent attach-
ment relationship, children may feel shame, anxiety, and fear about
their ability to regulate their emotions during separation and demon-
strate strong reactions associated with separation. This type of response
may occur when parents prolong the separation or angrily initiate and
threaten to use separation as a type of punishment. When these chil-
dren mature, they may attempt to avoid rejection by mirroring oth-
ers’ emotions instead of sharing their own feelings. They may either
suppress or not be able to identify their own emotions (Siegel, 1999).
As adults, they may demonstrate separation anxiety and may cling
to or try to maintain favor or connection with others. In a disorgan-
ized attachment relationship, the child experiences separation associ-
ated with their parents’ rage. Thus, the child not only experiences the
separation as loss of comfort and safety; they also experience fear for
their own safety with no support to regulate or understand their emo-
tions. In these cases, children develop mental states that are unregu-
lated and somewhat chaotic, linked to ingrained behavioral patterns
in reaction to associated stimuli, such as freezing, fighting, or fleeing.
As adults, they may demonstrate disorganized narratives about their
past relationships and inconsistent behaviors that promote, dismiss, or
avoid closeness in relationships. These behavioral attachment patterns
often vary across individuals and their unique history of trauma and/
or abuse (Siegel, 1999).
In contrast to infants with an insecure attachment pattern, infants
in a secure attachment relationship develop an effective intrapersonal
regulation system. Thus, the ability to regulate oneself is learned from
many social interactions and social contexts with nurturing caregivers.
62 • Hwa-Froelich

Through these attuned experiences and over time, children’s neuro-

logical and nervous systems develop a tolerance for and an ability to
regulate strong arousal and emotional reactions and achieve a mentally
and physiologically calm state (Egeland, Weinfield, Bosquet, & Cheng,
2000; Schore, 2001; Sroufe, 1997). Thus, developing a secure attachment
relationship enables children to initially use the caregiver as a means to
interpersonally regulate stress and negative emotions while they explore
the world. As children develop a mental model of their caregiver, as well
as social cognition and world knowledge, they learn strategies for inde-
pendently and intrapersonally regulating their stress and negative emo-
tions in the absence of the caregiver.
As in Anthony’s case, he developed an insecure attachment rela-
tionship in which his caregivers were the source of stress or negative
emotions and were unable or failed to provide attuned care. Children
in these situations may be unable to regulate strong arousal and nega-
tive emotions and may demonstrate unusual behavior patterns in the
face of stressful situations (Wilson, 2012). Caregivers may have pro-
vided inconsistent, intrusive, abusive, passive, or disconnected care. As
a result, their infants may be over- or under-aroused and may have a
poorly organized ANS (Egeland et al., 2000). Infants may not be able to
reach a calm state and may be inconsolable, withdrawn, or angry. Over
time, the inconsistent, ineffective, or abusive interactions leave children
in a chronic hypersensitive or hyposensitive state of arousal resulting in
persistent neurological stress patterns. These patterns of inappropriate
and ineffective regulatory systems become the default pattern for pro-
cessing and dealing with stress and negative emotions (refer to Chapter 1
for theoretical explanations). Children may display strong reactions to
external stressors (aggression, flight, or withdrawal) and are unable to
regulate themselves when stressed. For example, Anthony’s default pat-
tern when he felt scared or threatened was to become motionless and
freeze. By not talking to others, he demonstrated a passive, disconnected
interactional pattern with his family and others. Anthony did not have
external or internal sources to assist him in regulating his negative emo-
tional states. Children with insecure attachment relationships may be
reluctant to or may inappropriately explore their environment resulting
in learning delays. They may demonstrate physical growth deficiencies
because of persistent neuroendocrine stimulation in reaction to stress.
And they may have difficulty relating to others because they do not have
a close trusting relationship with their caregivers (Wilson, 2012). These
children may not be able to develop interpersonal or intrapersonal regu-
lation systems.
 Social-Emotional Development • 63

DEVELOPMENT OF EMPATHY
There is little research documenting the development of empathy. In
a discussion about variables involved in the development of empathy,
Knafo and Uzefovsky (2013) describe hypothetically how empathy
develops. From their perspective, empathy develops similar to, and is
associated with, other cognitive functions, such as self- and emotion
regulation and social understanding. They state that the infant must
first differentiate themselves from others, which typically occurs dur-
ing the first year of life. During this stage of “global empathy,” the infant
feels what others feel (becoming stressed when others are stressed) but
does not discriminate between their own feelings separate from oth-
ers’ feelings (Knafo & Uzefovsky, 2013, p. 100). For example Anthony
remained in a state of global empathy in which he felt the distress of
others but was unable to cope with others’ distress. After approximately
1 year, the infant moves to a stage of “egocentric empathic distress,” in
which he or she desires to be comforted when another person is upset
(Knafo & Uzefovsky, 2013, p. 100). At the age of 2 years, children dem-
onstrate “quasi-egocentric empathic distress,” when they recognize
someone else is distressed and offer solutions that would help alleviate
their own distress, not realizing that someone else may desire a different
solution (Knafo & Uzefovsky, 2013, p. 100). Later in the second year of
life, children begin to understand that other people may have differ-
ent feelings than their own or the state of “veridical empathic distress”
(Knafo & Uzefovsky, 2013, p. 100). There is emerging evidence showing
an increase in empathic concern during 14 to 20 months, 2 years, and
3 years of age (Knafo & Uzefovsky, 2013).

SELFREGULATION AND INHIBITION

Self-regulation involves learning how to manage affect, attention, and
behavior by inhibiting impulses (Barkley, 1997; Raffaelli, Crockett,  &
Shen, 2005). As infants learn to move from interpersonal to intraper-
sonal regulation, they learn coping strategies to inhibit negative emo-
tions. Initially, infants are able to stop or reduce their crying when their
caregiver attends to their physiological needs of hunger, distress, or
fatigue. As they mature, infants have a mental representation of their
caregiver or develop coping strategies to calm themselves in the absence
of their caregiver (Bronson, 2000). For example, infants may use a
stuffed animal or pacifier to calm themselves. Table  3.2 describes the
developmental changes in self-regulation.
64 • Hwa-Froelich

Table 3.2 Developmental Changes in Self-Regulation

Age Developmental Integrated develop- Outcomes
changes mental areas
2 months Moves from internal Demonstrates bio- Awake more often
control logical regulation Increased interac-
Develops sleep/ Attention/alertness tion
wakecycles increases
Inhibits primitive
reflexes
7–9 months Develops specific Mobility Position/place
attachments Has shared in environment
Connects emotion meanings changes
and behavior Intimate with others Changes expecta-
Self-soothing behav- tions of self/others
iors develop Displays negative
Beginning mobility reactions
Shows fear of
strangers
12 months Develops symbolic Increased mobility Explores world
behaviors Attached to parents Has a secure base
Expresses affect Shares emotions Expresses feelings
Increases mobility
18–21 Uses language Words, verbal Strong sense of
months Increases autonomy expression self
Aware of obstacles Aware of separation Resists control
Declarative knowl- Behavioral
edge/schemas self-control
30–48 Thinks in emotions Sense of self Understands
months Knows social rules Differentiates mistakes
Develops between fantasy/ Follows rules
self-concept reality Has new
Delays gratification Understands cause expectations and
and effect standards
48–96 Ability to shift at- Increase in abstract Predicts out-
months tention thinking comes and alters
Increase in inhibi- Flexibility in atten- behavior
tory control tion and thought Dynamic thinking
Decrease in impul- Increased social reflected in prob-
sivity understanding lem solving

Source:
Adapted from Bronson (2000); Emde, Gaensbauer, and Harmon (1976); Mischel, Shoda,
and Rodriguez (1989); Murphy, Eisenberg, Fabes, Shepard, and Guthrie (1999); and Raf-
faelli et al. (2005).

During the toddler and preschool ages, children learn to inhibit

three different kinds of impulses: (a) reflexes or unconscious impulses,
 Social-Emotional Development • 65

(b) ineffective actions, and (c) interfering or damaging actions affecting

task completion (Barkley, 1997). An example of inhibition of reflexive
or unconscious impulses is when they learn to inhibit a startle reflex for
repetitive and familiar sounds such as doorbells and telephone rings.
They learn to stop an ineffective action, for example, when they learn
to inhibit their desire to crawl down stairs face-first and turn around
to decline the stairs without seeing where they are going. Finally, they
learn how to interact with objects and to avoid sources that may dam-
age or interfere with completion of a task. For example, children learn
that parents do not want them to play with car keys or cell phones;
they inhibit playing with these forbidden objects in the presence of
their parents and run or hide when trying to operate or play with these
objects.
As described earlier, some inhibition and regulation of emotions,
attention, and behavior develop prior to learning language. Infants learn
to attend to their caregivers’ facial expressions to determine whether
they should engage with an object (Mundy & Sigman, 2006). As caregiv-
ers model and express directions and social rules in simple language to
their children, children initially learn to regulate their behavior in the
presence of the caregiver (Bronson, 2000). As children learn to under-
stand and express language, they begin to inhibit their impulses and
follow directions and social rules when their caregivers are not present
(Bronson, 2000; Vygotsky, 1934/1986). Over time, they begin to use lan-
guage or self-talk as a way to inhibit and regulate their behavior. For
example, children may talk aloud to inhibit touching something, saying,
“Mommy said, ‘Don’t touch.’ ”
Inhibition and self-regulation are related to caregivers’ sensitivity in
interacting with their children (Bernier et al., 2010). Measures of mater-
nal sensitivity, parent talk about mental states, and support for autonomy
when children were 15 months old were related to children’s working
memory development at 18 months of age and their executive function
abilities at 26 months of age more than children’s cognitive ability and
mothers’ education (Bernier et al., 2010). Parental support of autonomy
was defined as scaffolding, respect of individual differences in rate of
learning, and encouragement of child participation and role in success-
ful task completion. Over time, children are able to motivate themselves
and monitor their progress by independently analyzing and synthesizing
their behavior prior to, during, and after completion of a task. In other
words, the development of self-regulation allows children to inhibit
attention on distractions and focus their attention to complete tasks suc-
cessfully and competently (Welsh, Pennington, & Groisser, 1991; Zelazo,
Carter, Reznick,  & Frye, 1997). These sensitive parenting behaviors,
mental state talk, and support for their children’s autonomy (scaffolding,
66 • Hwa-Froelich

respect, and encouragement) facilitated and promoted executive func-

tion development, which are discussed further in Chapter 4.
After language develops, self-regulation development continues to
develop, and is integrated with, other developmental areas. For exam-
ple, Murphy and colleagues (1999) followed 4- to 6-year-old children
for 6 years longitudinally and found improvements in shifting attention
and inhibitory control with no change in focused attention and behav-
ior regulation. In a cross-sectional study of children between 6 and
12 years of age, improvements in self-regulation behaviors were related
to children’s improved ability in abstract thinking (Mischel et al.,
1989). Additionally, Raffaelli and colleagues (2005) compared paren-
tal report measures of regulation of emotion, behavior, and attention
when 646 children were between 4 and 5, 8 and 9, and 12 and 13 years
of age. They found significant improvement in self-regulation dur-
ing the period between early and middle childhood but not between
middle-childhood and adolescent ages. Gender differences were also
reported at each period (early childhood, middle childhood, and ado-
lescence) with girls demonstrating more regulation than boys (Raffaelli
et al., 2005).

FACTORS AFFECTING SOCIOEMOTIONAL DEVELOPMENT

Cultural differences in beliefs and values have been documented exten-
sively in the literature. Most cultural factors affecting socio-emotional
development can be organized into three categories: (a) the mind-set of
the caregivers, (b) the physical and social environment, and (c) cultural
habits in caring for and rearing children (Lewis, 2000).

Mind-Set of Caregivers
The importance of caregiver sensitivity on the development of the
caregiver–infant relationship affects attachment and a child’s closeness
in future relationships. According to mainstream and Western defini-
tions of caregiver sensitivity, sensitive caregiving includes responding
promptly, consistently, and appropriately. However, these interactions
may also be influenced by cultural preferences for independence or
interdependence (for a review see Lewis, 2000).
Some cultures prefer infant behaviors that promote child dependence
on the caregiver while other cultures may prefer caregiving behaviors
that encourage infant exploration and separation from parents to pro-
mote independence. For example, Puerto Rican mothers were found to
physically and verbally restrain their children’s exploration in contrast
 Social-Emotional Development • 67

to US mothers who encouraged more independent exploration and

gave more suggestions and fewer directions (Harwood, Schölmer-
ich,  & Schulze, 2000). On the other hand, Vietnamese parents talked
about using the threat of separation or shunning as methods to facilitate
dependence, filial obligation, and obedience (Hwa-Froelich & Westby,
2003). Each group of parents may view children’s reactions to separation
differently. If children cry on separation and desire to be reunited with their
parents, Asian parents may view this behavior as a sign of successful
parenting in that their child needs to renew their interdependence
with them. Consequently, Asian mothers expect and willingly provide
soothing assurances that they are still connected. On the other hand,
Western parents may view crying behavior and drive to reunite as con-
frontational, insecure behavior. Thus, to foster independence, Western
mothers may desire to eliminate this dependent behavior and apply
strategies and experiences to help their children separate from them
without crying (Harkness, Super,  & Mavridis, 2011; Rothbaum  &
Rusk, 2011). Given these cultural variations on how parents socialize
and discipline their children in exploration, separation, obedience, and
behavior, children may demonstrate differences in social and emotional
behaviors such as attachment.
Cultural differences in parent-infant attachment with more inse-
cure attachments were reported by Van IJzendoorn and Sagi-Schwartz
(2008). Children with insecure attachments were overrepresented in
some African countries as well as Japan, Indonesia, and Israel. How-
ever, they found more intracultural variation than inter-cultural varia-
tion (Van IJzendoorn & Sagi-Schwartz, 2008). Chen and Rubin (2011a)
reviewed the literature on children’s reactions to stressful situations and
found cultural differences. They reported that Korean and Chinese tod-
dlers appeared more fearful and anxious than Italian and Australian
children did in experimental situations. In another study, Chinese tod-
dlers demonstrated more vigilant and reactive behaviors than Canadian
toddlers did (Chen & Rubin, 2011a).
Differences in attunement may also be due to cultural differences in
values. In a study of 796 mother–infant dyads from 11 countries, the
majority of the mothers and infants demonstrated attuned behaviors.
Behaviors varied based on what value the mothers stressed; that is, if
physical development was stressed, the infants had more advanced
physical development, or if mothers stressed social interaction, the
infants demonstrated more social attention (Bornstein, 2013).
In spite of these cultural variations, the basic patterns of attach-
ment described in this chapter have been found in every culture
(Stevenson-Hinde, 2011). Because of the intracultural variation as well
68 • Hwa-Froelich

as intercultural differences, it is important for all professionals to be

aware that cultural beliefs and values influence caregiving and infant
behaviors and that these variances may not indicate a clinically rel-
evant insecure relationship. Professionals may need to gather informa-
tion from a local sample of parent–infant interactions to understand
cultural variances in parental beliefs and values and parent–infant
interactions before determining whether a clinically relevant insecure
attachment exists.

Physical and Social Environments

Physical and social environments include the settings where children
and their families live and interact, such as neighborhoods, schools,
parks, and the community at large. The social environment involves
the people who are responsible for the care of children and people with
whom children interact on a regular basis (Lewis, 2000). Poverty or low
socioeconomic status (SES) may have a detrimental influence on social
and emotional development particularly in the domain of physical and
social environments. Children from low-income backgrounds are more
likely to live with a single mother who did not finish high school and
may not be employed (for a review see Aber, Jones, & Cohen, 2000).
Single adolescent mothers may have had an insecure relationship
with their own parents and consequently their children may be at greater
risk of developing an insecure attachment relationship. Van IJzendoorn
and Bakermans-Kranenburg (2010) conducted a meta-analysis of stud-
ies employing the Adult Attachment Interview (Cassidy  & Shaver,
2008) across gender, SES, and culture. Adult attachment interviews are
structured interviews gathering narrative information about an adult’s
perspective of their childhood relationships with their parents. Based
on the coherence of these narratives, trained psychologists can derive
one of three attachment classifications: (a) Secure–Autonomous, (b)
Insecure–Dismissing, or (c) Insecure–Preoccupied. Adults who are
secure appreciate the importance of attachment relationships. Adults
with a dismissive insecure attachment may view the parent–child
relationship idealistically but are unable to describe relationships in
concrete terms or dismiss the importance of this relationship in their
lives. The preoccupied, insecure adult focuses on the negative impact
their previous attachment relationship had on their lives display-
ing anger or passivity toward these relationships (Cassidy  & Shaver,
2008). From this meta-analysis, more adolescents, in particular ado-
lescent mothers from low-income backgrounds, were judged to have a
dismissive insecure attachment with their parents (Van Ijzendoorn  &
Bakermans-Kranenburg, 2010). With this kind of socio-emotional
 Social-Emotional Development • 69

background, young adolescent mothers are at risk of replicating this

type of attachment relationship with their infants. In addition to the his-
tory of an insecure relationship, the risk of developing an insecure rela-
tionship with their children, because of their low-income status, these
families often reside in poor neighborhoods with poor-quality schools,
little or no access to health or public services, and more risk of exposure
to environmental toxins, such as lead.
The health and the development of children born into impoverished
environments are at risk. First, poverty is associated with poorer birth
outcomes. Infants born into poverty are more often associated with low
birth weight and at risk of high infant mortality (Aber et al., 2000). Once
they leave the hospital, these infants are also more likely to be exposed
to environmental lead and have elevated blood lead levels. Small or low
levels of lead have been shown to have negative effects on brain develop-
ment (Aber et al., 2000). Poverty has also been associated with poorer
health outcomes including a higher incidence of asthma, upper respira-
tory infections, tuberculosis, and pediatric AIDS (for a review, see Aber
et al., 2000).
In addition to environmental toxins, poor neighborhoods are often
unsafe and violent. Exposure to violence or experiencing violence can
have traumatic effects on children and their family. Long-term exposure
or experiencing a traumatic event can increase the stress on children and
their families resulting in a state of hypervigilence (Aber et al., 2000).

Cultural Habits in Child Rearing

Cultural habits in rearing children may develop from the beliefs and
values of a particular culture. Differences in display and regulation of
emotions have been reported in the literature (for a review see Chen &
Rubin, 2011b). Differences in smiling and laughing, differences in
sociodramatic or symbolic play (discussed in chapter  4), as well as
cultural differences in parenting behaviors have been reported (Chen,
2011; Chen & Rubin, 2011a; Hwa-Froelich, 2004; Hwa-Froelich & Vigil,
2004; Vigil  & Hwa-Froelich, 2004). Some of these differences may be
explained by differences in values of independence and interdepen-
dence or individualism versus collectivism (Hwa-Froelich & Vigil, 2004).
Chen (2011) describes these differences “while individuals in Western
societies attempt to maintain a balance between prosocial concerns and
individual freedom of choice, individuals in group-oriented societies
regard responsiveness to the needs of others as a fundamental commit-
ment” (p. 32). For example, in Ugandan and Kenyan African cultures,
a value of social responsibility is associated with being more intelligent.
Mothers will share taking care of infants with other mothers and older
70 • Hwa-Froelich

children. The ability to care for others is valued as a developmental skill.

Social skills are also viewed as an important developmental skill by par-
ents in Latin America. Latin American parents described their goal of
having children who were socially competent (e.g., respectful, coopera-
tive, fulfilling family obligations; Chen, 2011).
Cultures differ in their preferences for aggressive, assertive, shy, inhib-
ited, attentive, self-focused, or other-focused behavior (Chen, 2011). For
example, Korean children prefer to exclude aggressive peers, whereas in
the United States, some peer groups support and approve of aggressive
behaviors. A  shy, inhibited demeanor is often associated with insecu-
rity in Western societies, but in Asian ones, it is viewed as a positive
behavior and is associated with social maturity. US parents described
their infants in terms of intelligence and independent and rebellious
behaviors, whereas European parents (specifically parents from Italy,
the Netherlands, Spain, and Sweden) talked about their children’s social
and emotional characteristics in that they were “happy, well-balanced or
even-tempered” (Chen, 2011, p. 89).
Often these behaviors are taught or modeled by children’s parents.
Chen (2011) described literature in which Asian parent goals are to
teach children to be obedient and harmonious with others. Because of
these values, research has found that children from East Asian coun-
tries such as Japan and China tend to have better perspective taking and
show more concern for others than children from Western countries
do. Individuals from East Asian societies also use strategies to engage
in active, attentive listening instead of expressing individual ideas or
feelings and their emotions often reflect the emotions of others (Chen,
2011). Independent and interdependent differences in beliefs, goals, and
strategies for problem solving are compared in Table 3.3.
Different cultures also socialize children to display or suppress dif-
ferent emotions. In interdependent cultures in which the goal for chil-
dren is to achieve harmony, it is more likely that children may suppress
individual expressions of emotions and attend more to other people’s
emotions, whereas children from independent cultures are more likely
to express their individual positive emotions, while suppressing indi-
vidual negative emotions (Rothbaum  & Rusk, 2011). Rothbaum and
Rusk (2011) describe several studies that contrast the cultural parent-
ing differences in promoting emotional regulation. For example, East
Asian parents were found to promote “low-arousal positive emotions of
calm and peaceful” and “self-effacement” whereas European American
parents reinforced more “high-arousal positive emotions of excitement
and elation” and “self-esteem” (pp.  109, 110). Trommsdorf and Cole
(2011) reported some emotions are valued differently across cultures.
 Social-Emotional Development • 71

Table 3.3 Independent and Interdependent Views and Goals

Independence Interdependence
Self-concept Individualistic Collective
Control To control oneself To allow others to control
oneself
Social goals To achieve autonomy To achieve harmony
Emotion goals To be happy To be calm
Situational strategies To solve a problem by chang- To solve a problem by
ing the situation through attending and adjusting
initiation or determination of to a larger context (group
outcomes (self goals) goals) and accepting the
situation
Regulation strategies To achieve happiness through To achieve a sense of
expression of emotions, calm by suppression of
redirection of attention from emotions, redirection
negative to positive emotions of attention from self to
others’ emotions

Source:
Adapted from Table 5.1 in Rothbaum and Rusk (2011, p. 103).

For example, joy, happiness, and pride are often valued as positive emo-
tions in many Western cultures. However, Asian cultures tend to place
less value on these emotions, which may be viewed as being less sensi-
tive toward others and placing a child at odds with achieving calmness.
Another example is the negative emotion of shame. In most Western
cultures, shame is often associated with psychological disorders (inse-
cure attachment, depression) and viewed as a particularly negative and
harmful emotion in terms of harming one’s self-esteem. However, some
Asian cultures believe shame is an acceptable emotion because it assists
children in learning their place in a hierarchical society, to regret an
inappropriate behavior, and to learn how to maintain or achieve inter-
personal harmony (Trommsdorf & Cole, 2011).
For example, to support a collective family as in Anthony’s case, inter-
vention focused on creating safe environments, building a positive, lov-
ing relationship with his mother and grandparents as well as his uncle
who interacted with Anthony on a regular basis. Anthony attended
the early childhood special education program and received in-class
speech-language therapy following a relationship- and play-based
approach. The grandparents and occasionally the uncle provided child
care for Anthony when he was not attending preschool and while his
mother was working. Both the ECSE and the SLP worked with Mrs. Barber
and Mr. and Mrs. Lopez on building a close, positive relationship with
72 • Hwa-Froelich

Anthony by learning communication strategies to talk about emotions,

mental states, and perspectives and adapted play-based activities in cul-
turally appropriate ways. The social worker also gave them strategies
for positive discipline, resources for counseling support, and economic
resources for the mother who was trying to care for her sons while
divorcing her husband. As Anthony developed trusting relationships,
he slowly began to express himself and his feelings through nonverbal
communication and eventually began to express himself verbally at pre-
school. Over time, he felt safe enough to verbalize his thoughts with his
grandparents and his mother.

DISCUSSION QUESTIONS
1. How does an insecure attachment affect children’s learning?
2. If children have an insecure attachment relationship with their
parents, how does this affect their adult relationships?
3. How is caregiving related to the development of emotion regu-
lation?
4. How is emotion regulation related to self-regulation?
5. In what ways do caregiver beliefs and values affect emotional
development? Emotion regulation?
6. In what ways does the physical environment influence social
and emotional development?
7. In what ways do cultures differ in caregiving habits?
8. In what ways do cultural caregiving habits influence the social
and emotional development of children?

INSTRUCTIONAL RESOURCES
Websites
Association for Treatment and Training in the Attachment of Children: www.
attach.org/
Attachment Parenting International: www.attachmentparenting.org/
Center on Social and Emotional Foundations for Early Learning at Vanderbilt
University: http://csefel.vanderbilt.edu/
Department of Economic and Social Affairs (DESA): http://undesadspd.org/
CommissionforSocialDevelopment.aspx
Smith, M., Saisan, J., & Segal, J. (2013, June). Attachment disorders and reactive
attachment. Retrieved from www.helpguide.org/mental/parenting_bond
ing_reactive_attachment_disorder.htm
 Social-Emotional Development • 73

This Emotional Life. (n.d.). Retrieved from www.pbs.org/thisemotionallife/

topic/attachment
WebMD. (2012). Preschool emotional development. Retrieved from www.
webmd.com/parenting/guide/preschooler-emotional-development
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com/parenting/what-is-attachment-parenting
Zero to Three (2012). Development of social emotional skills. Retrieved from
www.zerotothree.org/child-development/social-emotional-development/
social-emotional-development.html

Video Resources
Arredondo, D. E. (2009). Attunement and why it matters [Video]. Retrieved from
www.youtube.com/watch?v=URpuKgKt9kg&list=PL2A0CF58E2C7D0AC3
Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive
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Baumeister, R. (2013). Experts in emotion 18.3—Roy Baumeister on self-
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Bergman, N. (2010). Dr. Nils Bergman on the social emotional intelligence of
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watch?v=aybKnSZ26Sw
Schore, A. (2013). Allan Schore neurobiology of secure attachment. Retrieved
from www.youtube.com/watch?v=WVuJ5KhpL34
Siegel, D. J. (2011). Dr. Dan Siegel—on ambivalent attachment. Retrieved from
www.youtube.com/watch?v=nGhZtUrpCuc
Siegel, D. J. (2011). Dr.  Dan Siegel—on avoidant attachment. Retrieved from
www.youtube.com/watch?v=qgYJ82kQIyg
Siegel, D. J. (2011). Dr.  Dan Siegel—on disorganized attachment. Retrieved
from www.youtube.com/watch?v=rpQtPsuhLzc
Siegel, D. J. (2009). Dr.  Dan Siegel—on integrating the two hemispheres of
our brains. Retrieved from www.youtube.com/watch?v=xPjhfUVgvOQ
74 • Hwa-Froelich

Siegel, D. J. (2012). Dr  Daniel Siegel, MD—we feel, therefore we learn: The
neuroscience of social emotion Retrieved from www.youtube.com/
watch?v=iPkaAevFHWU
Siegel, D. J. (2012). Dr.  Dan Siegel—on optimal attachment. Retrieved from
www.youtube.com/watch?v=_XjXv6zseA0
Tronick (2010). Still face experiment. Retrieved from www.youtube.com/
watch?v=Btg9PiT0sZg
Waters, E. (2011). Secure, insecure, avoidant,  & ambivalent attachment in
mothers and children. Retrieved from www.youtube.com/watch?v=DH1m_
ZMO7GU

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 4
DEVELOPMENT OF COGNITIVE PROCESSES
ASSOCIATED WITH SOCIAL COMMUNICATION
Deborah A. Hwa-Froelich

We all need contingent communication. Our history of being close

with others, having affective attunements and resonating states of mind,
allows us to connect with others and to have a sense of coherence within
our own internal processes. Adaptations to patterns of misattune-
ments without repair, and to the subsequent dreaded states of shame
and humiliation, shape our subjective experience of self, others, and
the world. These patterns of relationships can lead to a large disparity
between our adaptive, public selves and our inner, private selves. The
attachment models that reflect these early, pre-explicit-memory experi-
ences influence our emotions and their regulation, response flexibility,
consciousness, self-knowledge, narrative, and openness to and drive
toward interpersonal intimacy.
—Siegel (1999, p. 298)

LEARNING OBJECTIVES
Readers will
1. Be able to describe the development of attention, social cogni-
tion, memory, and their relationship to executive function.
2. Be able to discuss how intersubjectivity and inhibition are
related to the development of attention.
3. Gain knowledge about how social cognition, memory, play, and
social interaction are neurologically represented and develop-
mentally intertwined.
79
80 • Hwa-Froelich

4. Be exposed to how culture affects the brain, specifically atten-

tion, memory, and executive function.
Natalya was born in Russia and spent approximately 1 year in a Rus-
sian orphanage until she was adopted into the US. The orphanage staff
reported that Natalya was healthy with the exception of a few respira-
tory infections and had no history of ear infections. Natalya lives with
her mother, her father, and a younger sister, who was also adopted from
Russia. Her mother is a Mexican native whose dominant language is
Spanish. Her father is Caucasian and monolingual, speaking American
English. The mother reported that she spoke mostly Spanish to Natalya;
Natalya spent summers in Mexico visiting family members and had
recently been exposed to English when she started preschool at age 3.
Natalya was slow to learn English and was demonstrating inattention,
impulsivity, and inappropriate behaviors at preschool.
Prior to seeking an evaluation from an international adoption clinic,
Natalya was evaluated by an adoption medical clinic and the local early
childhood special education team. A pediatrician with training in Adop-
tion Medicine and experience assessing children adopted from abroad
evaluated Natalya at age 3. The doctor reported a history of immaturity,
lack of handedness, auditory hypersensitivity to noise, drooling, hyper-
activity, and short attention span as well as loss of focus. Natalya did not
meet criteria for fetal alcohol syndrome. Thus, the physician suggested
that these behaviors may be related to an immature or atypical ner-
vous system. The early childhood special education team completed an
evaluation of Natalya when she was 4 years old. All assessments were
administered in English with the assistance of a Spanish interpreter.
Natalya performed within one standard deviation (SD) of the mean
on an intelligence, articulation, and general language tests. Her verbal
intelligence quotient (IQ) and performance on another standardized
English language test were slightly more than 1 SD below the mean
with specific difficulty in English expressive vocabulary, morphology/
syntax, word retrieval, and answering questions. The team observed
that Natalya tended to seek sensory input, had difficulty attending in
noise, lacked persistence to complete tasks, and improved her perfor-
mance when reinforcement and redirection were provided. Based on
these findings, Natalya did not qualify for special education services but
instead received English as a Second Language (ESL) and emergent lit-
eracy intervention in the kindergarten classroom.
An international adoption clinic team conducted a developmental
assessment when Natalya was 5 years, 6 months old. While Natalya scored
within 1 SD of the mean on general Spanish and English standardized
 Development of Cognitive Processes • 81

assessments, she demonstrated significant delays in phonological

short-term memory and attention on Spanish and English nonword
repetition tasks, a selective attention go/no-go task, and forward and
backward digit span tasks. She also demonstrated these same areas of
difficulty during a play assessment. During administration of Theory of
Mind tasks in Spanish and English, she demonstrated a lack of under-
standing of her own and others’ perspectives. Auditory processing of
English stimuli was also delayed, particularly in auditory figure-ground
tasks, word discrimination, and word memory. These results indicated
that Natalya demonstrated significant delays in attention, memory, lin-
guistic processing, and social cognition, which may be affecting her
executive functioning and her performance in the classroom.
Children such as Natalya have been exposed to a variety of caregiver
inputs, making it challenging to determine whether her behaviors and
learning problems are due to the variability in her care and language
exposure or due to a true learning disorder. In order to make this deter-
mination, practitioners must understand how attention, social cogni-
tion, memory, and executive function develop in children raised in
environments that provide the nurturing care and experiences children
depend on and expect. The purpose of this chapter is to describe typi-
cal development of attention, social cognition, memory, and executive
function.

DEVELOPMENT OF ATTENTION, SOCIAL COGNITION,

MEMORY, AND EXECUTIVE FUNCTION
A complete and in-depth description of typical development in each
area is beyond the scope of this book. Instead, an abbreviated descrip-
tion of typical development in each area is provided to enable readers to
understand how these areas develop simultaneously and relate to social
communication development.
Growth and physical development of the brain is critical during the
early years of infancy and toddlerhood. The brain develops from back
to front and thus, the frontal lobes (important for executive function
abilities) develop later and are the last part of the brain to be myelin-
ated (Dunbar, 2013). Genetics, uterine environment, and postpartum
environment have a great impact on this development. Both maternal
nutrition and exposure to toxins have significant effects on infant devel-
opment in utero (Ladage  & Harris, 2012; Wilson, 2012). Most of the
neurons are present at birth and begin to develop synaptic connections,
which often operate in functional ways. In other words, neurons that fire
82 • Hwa-Froelich

together are connected, and the frequency of firing strengthens those

connections. After this neurological development, a stage of pruning
occurs in which connections that are used more frequently are main-
tained and those that are less frequently used are pruned (Ladage  &
Harris, 2012; Wilson, 2012). It is the type and frequency of early child-
hood experiences that influence which connections are saved and which
ones are lost. What this means is that children exposed to early adverse
care, such as poor prenatal care, toxins, and/or poor nutrition, are at risk
of poor neurological development, which may result in poorer cognitive
development, such as poorer attention, social understanding, memory,
and executive function skills.

Development of Attention
Three systems devoted to attention develop within the first year of life:
(a) the reticular activating system, (b) the posterior attentional system,
and (c) anterior attentional system (Calkins & Marcovitch, 2010). The
reticular activating system is hypothetically responsible for focusing on
stimuli and inhibiting distractions. The posterior attentional system is
thought to allow shifting of attention from one stimulus to another. The
anterior attentional system develops during the end of the first year and
is responsible for sensory regulation.
As soon as infants are born, they begin attending to objects and
people in their environments. During the first 6 months, they focus on
people’s faces and respond to eye gaze and facial expressions (Mundy,
2013). Trevarthen (1979, 1992) termed this face-to-face sharing of
feelings and mental states as primary intersubjectivity. The sharing of
emotions and mental states helps children learn about emotions commu-
nicated through facial expressions, tone of voice, and postures. Through
this face-to-face interaction, infants between 5 and 8 months of age
also discriminate, attend to, and imitate mouth and tongue movements,
as well as sounds from their native language (Legerstee, 2005; Moon,
Cooper, & Fifer, 1993; Mundy, 2013; Nazzi, Jusczyk, & Johnson, 2000).
Infants begin to switch their attention from one stimulus to another and
alternate gaze around 4 to 6 months of age (Mundy, 2013). This shift in
attention requires some development of self-regulation (i.e., inhibition
of attention from one stimulus to focus attention on another). In other
words, attention and self-regulation seem to develop concurrently and
lead to the development of secondary intersubjectivity.
Secondary intersubjectivity occurs around 5 to 6 months of age when
infants are able to share their attention between another person and an
object or event (Legerstee, 2005; Mundy & Sigman, 2006). Infants begin
to follow their caregivers’ directed gaze, gesture, or head turn toward
 Development of Cognitive Processes • 83

an object or event around 8 to 10 months of age (Corkum  & Moore,

1998; Morales, Mundy, & Rojas, 1998; Mundy & Sigman, 2006). Around
10 months of age, infants will react to and communicate their feelings
about an object or event to others in two different ways. First, they initi-
ate joint attention, which involves looking at the object and then look-
ing back at the adult. Infants also regulate the other person’s behavior
by gazing at, shaking, or pointing to an object to direct the adult’s eye
gaze and to check to see if the adult is looking at the object (Mundy &
Sigman, 2006). Through these actions, the infant is asking the other
person if he or she sees what the infant sees and whether the infant
should engage with this object. Over the next 8 months, infants refine
and develop their intentional nonverbal communication abilities by ini-
tiating joint attention and regulating others’ behaviors to achieve joint
attention. The infants’ desires to share experiences, socially engage, and
interact with others are what drive these attention-seeking behaviors.
These behaviors tend to occur prior to and simultaneously with infants’
social communication of wants and needs (Legerstee, 2005; Moses,
Baldwin, Rosicky, & Tidball, 2001; Mundy & Sigman, 2006). Secondary
intersubjectivity, initiated joint attention, and response to joint attention
are related to inhibition, self-regulation, interpretation of nonverbal
expression of emotions, and social cognitive development (for a review
see Mundy & Sigman, 2006; Shin, 2012). Thus, joint attention is neces-
sary for social competence and communication.
Attention and inhibition skills enable children to solve problems, per-
sist at a task until it is mastered and take on a role during symbolic play
(attention and inhibition related to emotion and self-regulation are dis-
cussed in Chapter 3). When solving a problem, negative emotions such as
frustration can occur and children must inhibit their frustration to selec-
tively attend, focus, and persist in order to be successful. When initially
confronted with a novel toy that requires specific behavioral responses
for activation, children may use trial-and-error problem-solving tech-
niques. While trying different approaches, they must inhibit methods
that are ineffective and refine their behaviors to effectively manipulate
the toy. Their attention must be focused on the parts and characteristics
of the toy that are essential for operating the toy. For example, some
pop-up toys require five different movements to successfully open all the
boxes, sometimes pushing and other times turning or sliding different
knobs and buttons. Other toys may require putting an object in a slot
and pressing a button or a lever to cause the object to slide down a ramp.
Children must inhibit ineffective strategies such as pushing the object
or shaking the ramp, focus their attention, and learn the appropriate
behavioral sequence to successfully operate the toy. When engaged in
84 • Hwa-Froelich

symbolic or pretend play, they must also inhibit their actions and way of
talking to pretend to be someone else. For example if they are pretend-
ing to be a doctor, they must regulate themselves to take on the persona
of a pretend doctor. By pretending that an object represents something
else, such as pretending that a rope is a snake or a fire hose, they have to
inhibit using a rope for typical purposes and use it as a hose or treat it
like a live snake.
Inhibition and focused attention are important components of
working memory and executive function (Brocki, Eninger, Thorell, &
Bohlin, 2010; Kofler, Rapport, Bolden, Sarver, & Raiker, 2010). For example,
inhibition and selective attention skills at 5 years of age predicted work-
ing memory skills at 6  years of age (Brocki et  al., 2010). Focused, as
opposed to divided, attention was important for working memory
capacity (Kofler et  al., 2010). Poor behavioral inhibition and negative
behaviors measured at 2 years of age were correlated with poorer The-
ory of Mind (ToM) performance, a measure of social understanding, at
3 years of age (Suway, Degman, Sussman, & Fox, 2011). Thus, inhibition
and selective, focused attention are important skills for later working
memory and ToM, which are important for solving problems, social
understanding, and interpersonal communication at older ages.

Social Understanding
It is primarily through consistent and contingent face-to-face interactions
or intersubjectivity that infants learn to share emotional states with their
caregiver, identify and regulate their own emotional states, and draw
inferences about their own and others’ mental states from their care-
givers’ nonverbal and verbal communication (Baldwin & Moses, 1994;
Butterworth, 1994; Legerstee, 2005; Moses et al., 2001; Smith, 2005;
Trevarthen, 1979, 1992). Nonverbal aspects of the communicated mes-
sage include facial expressions, tone of voice, and physical movements
associated with the social context. Perceptions of these face-to-face
interactions help infants’ access and use adult mental states to facili-
tate emotional understanding, resolve infant’s uncertainty about their
own emotional states, and help infants begin to identify their own
feelings (Smith, 2005). These child–caregiver social, emotional, and
communicative interactions facilitate infants’ abilities to develop social
understanding and knowledge about their own emotions, desires, and
intentions (Perner, 1991; Zeedyk, 1996). As self-awareness of feelings
and intentions develop during the first 4 to 6 months of life, infants
begin to have an emerging sense of self and intra-ToM (Legerstee, 2005).
“Intra-ToM is the ability to identify one’s own thoughts and feelings,
knowing what one knows and does not know and determining how to
access what one does not know” (Hwa-Froelich, 2012, p. 180). Initially
 Development of Cognitive Processes • 85

infants develop a sense of animacy. Infants as young as 5- and 8-weeks-

old imitated gestures, and by 2 to 4 months of age, they imitated mouth
movements demonstrated by a person but not gestures or mouth move-
ments of an inanimate object (for a review see Legerstee, 2013). This
emerging social knowledge reflects the development of cognitive and
affective cognitive ToM as defined in Chapter 2. Refer to Table 4.1 for
developmental stages of ToM.
They begin to learn inter-ToM through primary and secondary inter-
subjectivity. Inter-ToM is the awareness that other people have thoughts
and feelings that may be different from one’s own thoughts and feel-
ings, may be caused by certain events, or their feelings and thoughts
may cause them to act in certain ways (Baron-Cohen, 1997). This social
cognition about the relationship between people’s emotions, behaviors,
and causative events allows children to predict what others are thinking
from what the children know about them and the world (social cogni-
tion), and to use this social cognition to understand or respond to a

Table 4.1 Stages of Theory of Mind Development (Miller, 2012; Westby, 1999)

4–6 months Has an emerging sense of self and enjoys primary intersub-
jectivity
5–6 months Responds to joint attention with objects and begins to fol-
low line of regard
9–15 months Initiates joint attention and behavioral requests with oth-
ers often involving an object, event, or person (secondary
intersubjectivity)
18–24 months Engages in pretend; understands desires
Has implicit ToM, understands relations between line of
sight and behavior
3 years Understands people see world differently; understands
imaginary objects are different from real
4–5 years Has explicit ToM:
Knows different viewpoints lead others to different inter-
pretations
Understands beliefs cause people to act in certain ways
Understands someone will act differently because of a false belief
Understands deception is a means of creating false beliefs
6–8 years Appropriately judges situations when one remembers,
knows, forgets, or guesses, thinks about what someone else
is thinking about (second-order ToM)
8–12 years Understands strategies to hide and detect deceit, higher
levels of affective and cognitive ToM in inferential language
(lies, sarcasm, puns, idioms, etc.)

Sources:
Miller, 2012; Westby, 1999.
86 • Hwa-Froelich

particular social situation (Garfield, Peterson, & Perry, 2001; Wellman,

Phillips, & Rodriguez, 2000; Zeedyk, 1996). Infants between the ages of
3 and 8 months begin to understand the actions of others before they
can interpret the goals associated with these actions (for a review see
Mundy, 2013). By 9 months of age, they begin to understand behav-
ior to achieve a goal such as sharing action and attention during ball
play. Children who are approximately 12 to 15 months old understand
people’s choices and demonstrate the understanding that that others
may make different decisions (through joint attention) about interact-
ing with an object or during an event (Mundy, 2013). During the first
2  years of life, infants know how people behave before they begin to
understand how they think (Legerstee, 2013).
Typically developing children implicitly acquire intra- and inter-ToM,
which involves an understanding of self and others’ mental states; the
ability to draw inferences about others’ mental states, intentions, and
perspectives; and an understanding of deception and false beliefs or
first-order ToM. This social understanding has frequently been meas-
ured through the administration of false belief tasks (for a review see
Miller, 2012). Having a false belief is when persons behave a certain
way when they believe something is true while being unaware that the
reality of their belief has changed. For example, children can observe
their sibling moving their mother’s car keys from the table to the couch
when the mother is not in the room. When the mother looks for her car
keys, children may point to the couch (implicit social understanding)
because they know their mother believes she left the keys on the table
(false belief) and did not see their sibling who moved the keys to the
couch (Hwa-Froelich, 2012; Miller, 2012). Implicit social understand-
ing of mistaken beliefs develops prior to explicit social understanding,
which is the ability to explain why someone has a false belief and how
that false belief affects his or her actions. Implicit social knowledge
underlies children’s ability to communicate about this knowledge (Low,
2010). Several studies have documented that implicit false belief perfor-
mance is present in children between the ages of 14 and 24 months by
measuring the eye gaze of 2 year-old children during tasks involving a
relocation of specific objects (Low, 2010; for a review see Sabbagh, Ben-
son, & Kuhlmeier, 2013).
Children’s explicit communication about false beliefs in children
develops between 3 and 4 years of age and is correlated with and pre-
dicted by communicative competence (Astington  & Jenkins, 1999;
Legerstee, 2005; Lewis  & Osborne, 1990; Low, 2010; Perner  & Lang,
1999). As children gain knowledge through social experiences with
others and social talk about emotions, their social understanding and
 Development of Cognitive Processes • 87

communicative competence improve simultaneously. Jill de Villiers and

Peter de Villiers (2000) proposed that children must develop linguistic
complementation in order to pass false belief tasks. For example, expres-
sion of mental states in the English language requires the use of depend-
ent clauses such as The wolf knew where Granny lived. The de Villiers’
research has provided much evidence that general language ability and
complex grammatical knowledge are correlated with performance on
false belief tasks (for a review see Carpendale & Lewis, 2006, p. 172).
However, this theory has come into question when children whose lan-
guage (e.g., Cantonese, Mandarin, German) allows them to talk about
desire and belief using less complex grammatical structures developed
social understanding at about the same age as US children (for a review
see Carpendale  & Lewis, 2006, pp.  171–172). In these cases, under-
standing of false belief was not dependent on complementation or com-
plex grammatical structures. Rather, false belief may be related to the
knowledge and use of mental state words. For example, in cultures and
languages in which there are few mental state words, social understand-
ing develops later than in cultures and languages that include words for
emotions and mental states. These differences are discussed in a later
section of this chapter.
Social understanding of emotions improves with age (Miller, 2012;
Pons, Harris, & de Rosnay, 2004). In a cross-sectional study of 100 chil-
dren between the ages of 3 and 11  years, Pons and colleagues docu-
mented that emotional understanding developed in three stages and
that there were no statistically significant differences between boys and
girls. Three- to 5-year-olds are able to recognize emotions displayed in
facial expressions, understand how external causes affect emotion, and
the relationship between memory and emotion (i.e., how intensity of
emotion diminishes over time). Five- to 7-year-olds understand that a
person’s belief will affect their actions, regardless of whether their belief
is false or true (first-order ToM). They also understand that persons’
desires are related to their emotional reactions and that people may dis-
play one emotion while feeling another (Pons et  al., 2004). Knowing
what another person is thinking or feeling about what someone else is
thinking or feeling is second-order ToM, which develops around the age
of 7 years (Miller, 2012). Later, 9- to 11-year-olds may use psychologi-
cal strategies (distraction) to regulate their emotions, understand that
people can have multiple or mixed emotions about a particular event,
and begin to relate moral judgments with emotions (negative emotions
are related to amoral actions such as bullying and positive emotions are
related to moral actions such as sacrifice for the greater good). ToM
abilities higher than second order that enable children to understand
88 • Hwa-Froelich

figurative language, idioms, lies, and sarcasm develop between 8 and

12 years of age (for a review see Miller, 2012).
Social understanding of false beliefs has been found to be related
to metalinguistic abilities such as rhyming but not inhibitory control
(Farrar & Ashwell, 2012). Four-year-old children completed a vocabu-
lary measure; three ToM tasks, (a) an unexpected location task, (b) an
unexpected contents task, and (c) an unexpected identity task; and a
color-sorting task that switched to a shape-sorting task using the same
stimuli as a measure of inhibitory control. The rhyming tasks involved
20 sets of three words. Ten sets included a foil that was semantically
associated with one of the rhyming words and a set of 10 words that
did not have a semantic foil. ToM scores were positively correlated with
the vocabulary score and both sets of rhyming words, but not with the
measure of inhibitory control (Farrar & Ashwell, 2012). In other words,
social understanding appears to be strongly associated with vocabulary
and metalinguistic knowledge.

Development of Memory
Although attention, emotion, and memory are mental actions we can
describe, little is known about how neurological activity is related to
or results in mental experiences. Therefore, this section describes the
current state of scientific and theoretical knowledge. Memory can be
described as the process of how past experiences affect the brain’s future
responses (Siegel, 1999). It is theorized that memories are built from
repeated and systematic neuronal firing patterns that encode, store, and
retrieve previous experiences (Siegel, 1999). Thus, infant neurological
development is dependent on and expecting to be exposed to care and
experiences that accelerate neurological growth, neural connectivity,
coherence, and integration. Infants must be exposed to the process of
encoding, storing, and retrieving memories to develop, use, and main-
tain neuronal memory connections (Siegel & Hartsell, 2003). This neu-
ral stimulation and growth forms the foundations for higher and more
complex and dynamic cognitive thought. For example, Siegel (1999)
hypothesizes that short-term memory may be represented as transient
neuronal changes, whereas long-term memory may involve structural
changes that form the foundations for higher level cognitive processes.
While many different theories about memory exist, for the purposes
of this chapter, memory will be described generally as two major compo-
nents; implicit (sometimes referred to as nondeclarative memory) and
explicit (declarative) memory. These components involve additional
different, overlapping, and dynamically integrated neurological sys-
tems (Fivush, 2011). Implicit memories can be described as unconscious
 Development of Cognitive Processes • 89

summaries of mental or perceptual models of an experience and

is associated with such brain structures as the amygdala and the lim-
bic system. The limbic system includes the basal ganglia and the motor
cortex for behavioral memory and the perceptual cortex for perceptual
memory (Siegel, 1999). From repeated experiences, the brain processes
experience similarities and differences to create mental models of these
experiences. These mental or perceptual models include procedural
memories (emotional, behavioral, sensory, or physical body models),
such as implicit procedural memories for the actions of sitting, walking,
or standing (Fivush, 2011; Hwa-Froelich, 2012). Implicit memories can
be represented in the developing sense of self in that infants begin to
sense who is most like them through early interactions with caregivers.
This developing sense of self can be seen in 2- to 3-month-old infants’
early preferences for human interaction or interest, extended attention
on humanlike stimuli such as pictures or drawings of faces, and discrim-
ination between humans and objects (Legerstee, 2005). This implicit
memory is also evident after approximately 1 to 3 months of age, when
infants imitate mouth and tongue movements of other humans but
not those of an inanimate object (Legerstee, 2005). Implicit memories
include visual and sensory memories associated with facial expressions,
tone of voice, body postures, tactile, and olfactory memories.
Explicit memory can be described as conscious summaries of events
(episodic memory), words, or concepts (semantic memory; Siegel  &
Hartsell, 2003). As infants respond to their environment, they collect
information about objects, humans and other animate beings, actions,
emotions or mental states, routines or events. Research with infants has
provided evidence of event recall in 3- and 9-month-old infants (for a
review see Fivush, 2011). If their caretakers provide nonverbal and verbal
communication in association with the infants’ interactions, infants begin
to develop an associated explicit memory of abstract symbols (vocabu-
lary, categories, concepts, gestures, or semantic memory) with which
to interpret or imitate during social interactions. These conscious non-
verbal and verbal explicit memories are the building blocks for future
internal and external narratives about their experiences (Siegel, 1999).
Around 9 months of age, children develop object permanence; that is,
they recognize something continues to exist, even when it is out of sight,
and they will look for a hidden or missing object (Siegel  & Hartsell,
2003). Infants demonstrate the emerging representation (object perma-
nence) of their parents by crying when the parents are not visible. By 12
to 15 months of age, infants also begin to use words to represent their
caregivers and express a label (mama or dada) to gain their caregivers’
attention or regulate their caregivers’ behaviors (Siegel & Hartsell, 2003).
90 • Hwa-Froelich

Around 18 months of age as the hippocampus matures, it is thought

that toddlers’ explicit memory development involves the encoding pro-
cesses of implicit memory through the hippocampus (Siegel  & Hart-
sell, 2003). Experiences are contextualized beyond unconscious mental
models to form mental representations of experiences. In order to build
mental representations, it is thought that children must move explicit
memory from short-term storage to long-term storage or cortical con-
solidation (Siegel, 1999). Although the consolidation process is not fully
understood, it seems to involve Rapid Eye Movement (REM) sleep and
continued maturation of the frontal lobes (Siegel, 1999; Siegel & Hart-
sell, 2003). Children may also process past experiences through pre-
tend play allowing them to replay experiences to encode and retrieve
the experience over and over, which may be another process of cortical
consolidation.
Maturation between 1 and 5 years of age brings the development of
expressive language and a more individualized sense of self. The interac-
tion of these two developmental domains facilitates growth of semantic
memory (knowledge of facts) and episodic memory (recall for previous
situations, events, or personal experiences) and autonoetic conscious-
ness or autobiographical memory (the sense of oneself currently and
one’s associated feelings at the time of the event, currently and how one
would feel about the same event in the future; Carpendale & Lewis, 2006;
Fivush, 2011). For example, I have knowledge about a surgery I had but
do not have an episodic memory of what transpired during the surgery
except for what the doctor shared (semantic memory). In contrast,
I remember implicitly and explicitly my feelings and thoughts associated
with the birth of my children (episodic and autobiographical memory).
One must develop a sense of self or intra-theory of mind to develop a
sense of self across time or autobiographical memory (Fivush, 2011).
Measuring the development of autobiographical memory is linked with
the development of verbal language and narratives, the vehicle through
which one can share their experiences and feelings with others. Thus,
the development of episodic and autobiographical memory is important
for the development of social understanding of self and others.
Research has shown that mothers who provide elaborative discourse
with rich descriptions and extensions about the topic as well as engage
with the child during interactions with an object or an event have chil-
dren who are more engaged and demonstrate better recall of the event
or interaction (Bauer, 2013; Fivush, 2011). When caregivers have con-
versations about the child’s experiences, they create for the child a
self-narrative or declarative memory about those experiences and the
child’s feelings associated with the event. An elaborative style includes
 Development of Cognitive Processes • 91

open-ended questions that provide some information and facilitate

children’s recall of the event. This style also involves the parent includ-
ing the child’s responses into the narrative (Fivush, 2011; Siegel, 1999).
For example, 3- and 4-year-old children are able to plan based on inter-
nal goals and desires. Thus, they can plan future events from current
self-awareness of desires. However, it is not until they are 5 years old,
that they are able to link past experiences with the present. It is thought
that cortical consolidation of the child’s sense of self and expressive lan-
guage is complete by the age of 5, which allows for the expression of
autobiographical memory (Fivush, 2011; Siegel & Hartsell, 2003). The
ability to link time concepts and causality with past, present and future
events does not develop until the age of 12 years, and these skills develop
in complexity through adolescence.
Stress and trauma can have negative effects on memory. Small and
moderate amounts have less effect than do large or consistent stress and
trauma, which can result in the destructive pruning of neuronal growth
(Siegel, 1999). Research with children adopted from institutional care
has provided evidence that these children were able to encode informa-
tion in immediate recall tasks but were less skilled for a delayed memory
task. These differences may indicate problems with initial consolidation
of information for long-term memory (Kroupina, Bauer, Gunnar,  &
Johnson, 2010). In addition, children who have been exposed to trauma
or stress may have implicit memories that remain intact, while explicit
memories may be blocked. In other words, individuals may demon-
strate unconscious behavioral reactions to associated stimuli of past
experiences but may not be able to describe their feelings or thoughts.
There may be a disconnect between their implicit and explicit memories
(Siegel, 1999).

Representations
Mental representations are an individual’s perspective or image of
reality (Siegel, 1999). Children often demonstrate mental representa-
tions through play and eventually share their representations with others
through verbal communication. Representative or play development
can be described across four dimensions: (a) decontextualization, (b),
themes, (c) theme organization, and (d) self and other relationships
(Westby, 2000). Development of decontextualization involves knowl-
edge and understanding of objects’ functions and of how one uses these
objects. Around 5 to 9 months of age, infants develop models of object
function called schemas. These schemas typically include exploratory
behaviors such as hitting, banging, mouthing, and throwing (Linder,
2008). By approximately 8 to 12 months, infants interact with life-like
92 • Hwa-Froelich

objects and imitate functions they have experienced or observed such

as using a spoon to feed themselves (Linder, 2008; Westby, 2000). Chil-
dren begin to decontextualize their play around 2 to 3 years of age by
pretending to eat and drink with child-size replicas, miniature pretend
food, or nonexistent food. By approximately 3.5 and 4 years of age, chil-
dren understand knowledge as a representation for reality and share
their perception of reality through language (Carpendale & Lewis, 2006;
Siegel, 1999). They use language to describe the scene (“I’m talking to the
police”) with pretend props to substitute for the real object such as a bowl
as a hat or a hand gesture as if they are holding an imaginary set of keys to
start a car or open a locked door (Linder, 2008; Westby, 2000). Children
use short-term and long-term memory of objects, object functions, and
ways to play with objects that may not be present or available in the play
context using their memory of the size, shape, and function of the object.
Themes of life or mental scripts of activities, both experienced and not
experienced by children are also represented in children’s play (Lillard,
1994; Westby, 2000). Between 15 and 24 months of age, children pre-
tend to carry out typical daily routines such as sleeping or eating. Then
around 2 and 3 years of age, children’s play themes include events that
occur often but perhaps not every day, such as shopping at a store or
going to the doctor. Around 3 to 5 years of age, children’s play will include
pretend or fantasy themes they have observed but not experienced, such
as putting out a fire like a firefighter or pretending to be an astronaut fly-
ing to the moon (D. Singer, Golinkoff, Hirsh-Pasek, 2006; Westby, 2000).
These representational themes become more complex as children
mature (Westby, 2000). Prior to 2 years of age, 17- to 22-month-old chil-
dren may use two or three objects and demonstrate two or three steps
in their play. For example, they may use a bottle to feed a doll. As mem-
ory of routines, objects, and functions increase, children mentally plan
and sequence events, which requires the use of self-regulation, working
memory, and executive function skills. For example, 2- to 3-year-old
children may set the table and fix food on a stove to put on the plates on
the table before they sit down to pretend to eat and then clear the table
and wash the dishes. This level of play facilitates the executive func-
tion to plan complex play episodes by combining multiple objects and
themes, such as combining the theme of cooking breakfast with a theme
of starting a fire and adding a third theme of the baby getting hurt and
needing to go to the hospital. This play complexity typically develops
between 4 and 6 years of age.
The last dimension of play development, self and other relationships,
integrates social and cognitive knowledge with decontextualization,
themes, and thematic organization (Westby, 2000). Initially infants and
 Development of Cognitive Processes • 93

toddlers pretend on themselves, such as pretending to eat or sleep. By

the time they are between 17 and 22 months old, children may pre-
tend to feed, bathe, or operate on their dolls or stuffed animals. After
2 to 3 years of age, they begin to have conversations with their doll or
stuffed animals and their dolls/animals can talk back to them. Children
also begin to act out episodes in which their dolls or stuffed animals
have false beliefs, play tricks on others, and have emotions. Eventually
around 4 to 6 years of age, children learn to pretend to be other people
and their play reflects the perspective, voice, actions, and beliefs of the
character they represent (Diamond, 2000; Westby, 2000). To take on a
role of someone else means children have to inhibit their own personal-
ity traits, focus their attention to pretend to be someone else, plan and
set goals, and organize props and behavior while also monitoring their
own behavior (Berk, Mann, & Ogan, 2006; Perner, 1991). Through these
dimensions of play development, children refine their skills of inhibi-
tion, self-regulation, attention, social understanding, and memory.

Executive Function
Singer and Bashir (1999) describe executive function as a set of mental
processes which involves “inhibiting actions, restraining and delaying
responses, attending selectively, setting goals, planning, and organiz-
ing, as well as maintaining and shifting set” (B. Singer & Bashir, 1999,
p.  266). Because executive function is integrally related to selective/
focused attention and working memory, these mental processes are
often activated simultaneously (Barkley, 1996, 1997; Cowan & Alloway,
2009; Cowan & Courage, 2009; National Center for Learning Disabili-
ties, 2005; Pennington & Ozonoff, 1996; B. Singer & Bashir, 1999). Exec-
utive function has been related to mathematical ability, reading ability,
verbal and nonverbal reasoning, academic achievement, communica-
tion, social skills, social understanding, and emotion regulation (for
a review see Bernier, Carlson, & Whipple, 2010, Carpendale & Lewis,
2006). Processes related to executive function emerge prior to age 3 such
as attentional and cognitive control between 1 to 3 months of age. How-
ever, significant development in executive function occurs between the
ages of 3 and 5 years (Calkins & Marcovitch, 2010). For example, Müller
and colleagues (2012) found that executive function performance at age
2 and 3 predicted social understanding at age 3 and 4. Language per-
formance at age 3 was found to mediate the relationship between social
understanding and executive function when the children were 4 years
old (Müller, Liebermann-Finestone, Carpendale, Hammond, & Bibok,
2012). In other words, executive function is integrally involved and
important in the development of social understanding and language.
94 • Hwa-Froelich

For executive function to be fully effective, children need to develop

selective attention, working memory, self-regulation, and inhibition
skills. Selective attention requires regulation of emotions such as excite-
ment, fear, or frustration and inhibition of attention to nonessential
information or distractions in order to monitor oneself, focus, per-
sist, and think flexibly to complete the task at hand. Flexible thinking
involves working memory. Baddeley (1992) defined working memory
as “a brain system that provides temporary storage and manipulation of
the information necessary for such complex cognitive tasks as language
comprehension, learning, and reasoning” (p.  556). Working memory
can be described as online processing of both long-term and short-term
memories. It flexibly manipulates this information, which allows chil-
dren to outline possible solutions as well as plan and organize the steps
and materials needed to solve a problem or finish a task. Some compo-
nents of executive function, such as attention and self-regulation, begin
to develop in infancy (Bernier et  al., 2010; Diamond, 2000; Reznick,
2009). Executive skills in young children can be measured through dis-
crimination of error, delay of gratification, or Simon Says (go/no-go)
tasks. Children as young as 18- to 24-months-old were able to identify
errors in block constructions, 4-year-old children were able to delay
gratification (inhibiting eating one food to wait for a larger amount of
food), and 4- to 5-year-old children were successful at inhibiting actions
and following directions when Simon says them (for a review see Zelazo,
Carlson, & Kesek, 2008).
Most of these skills continue to develop and are refined as children
interact with different people, contexts, and problems. In a study with
participants ranging from 8 to 64 years of age, De Luca and colleagues
(2003) found that different executive function skills are stronger at dif-
ferent age levels. For example, the ability to shift attention reached adult
levels in 8- to 10-year-old children, strategic planning and organization
of goal-directed behavior peaked between 20 and 29 years of age, but
effective planning and problem-solving improved from 12 to 14 years of
age and declined in the 50 to 64 age group.

FACTORS AFFECTING ATTENTION, SOCIAL

UNDERSTANDING, MEMORY, AND EXECUTIVE FUNCTION
Contextual and Relationship Factors
Culture is passed from generation to generation through implicit and
explicit socialization and preferred ways of teaching. Children become
socialized to learn in certain ways (Hall, 1976; Hofstede, 2001). Some
 Development of Cognitive Processes • 95

cultures promote teaching that is within and dependent on the context.

Consequently, children become accustomed to learning that is linked
to contextual information. In contrast, some cultures teach with less
dependence on the context or a decontextualized instructional style.
Western cultures tend to support low-context learning, and Eastern
cultures tend to support high-context learning (for a review see Park &
Huang, 2010).
Hofstede (2001) studied cultures around the world and documented
differences along several different dimensions, such as individualistic
or collective tendencies. When cultures are more focused on self-goals
and motivations, they are judged to be more individualistic. In contrast,
when cultures pay more attention to group goals and interests, they are
more collective. Western cultures tend to be more individualistic and
Eastern cultures tend to be more collective (Park & Huang, 2010). These
differences in values have been found to affect executive functioning
performance as well as how persons process and organize information
and what types of things individuals attend to and remember.
Cultural Differences in Attention
Several behavioral studies have compared East Asian and American
participants. East Asian adults were found to demonstrate a bias toward
attending to and processing context, encoding information holistically,
relying less on categories and using more intuitive reasoning (Bodu-
roglu, Shah,  & Nisbett, 2009; Park  & Huang, 2010). Park and Huang
(2010) reviewed studies on eye gaze and found that when presented
with embedded objects in pictures, adult Westerners fixated their gaze
on the objects while East Asian adults tended to gaze less at the object
and focus more on the background scenes. However, in some contexts,
East Asians will focus more centrally and Westerners will attend to
stimuli more holistically. They also reported on research in which East
Asians attended longer on a focal face region while Westerners scan the
face and research showing cultural differences in interpretation of facial
expressions, such as facial displays of fear and disgust. Thus, cultural
experiences may affect interpretation of social context and facial expres-
sions.
Cultural Differences in Social Understanding
Social understanding appears to be related to many familial factors
across several countries including Australia, Canada, England, Greece,
and Japan. Children from these countries, who lived close to older chil-
dren or lived with older siblings demonstrated better social understand-
ing than children who did not live near or with older children (for a
96 • Hwa-Froelich

review see Carpendale & Lewis, 2006, p. 136). Children demonstrated

greater social understanding when they had parents, who explicitly
talked about mental states and displayed sensitivity during interac-
tions with their children. On the other hand, having authoritarian par-
ents who used criticism, yelling, or spanking was negatively correlated
with social understanding (Carpendale  & Lewis, 2006). For example,
in a study with 5-year-old children, a higher socioeconomic status and
mothers employed in skilled jobs who provided their children with
social context and support, space to play, positive discipline, and qual-
ity child care predicted a higher level of ToM performance (Galende,
Sánchez de Miguel, & Arranz, 2011).
Children from hierarchical cultures where elders have more power
and authoritarian parenting styles are preferred may demonstrate
poorer performance on false belief tasks. In contrast, in cultures where
individualism and equality are promoted, children may demonstrate
better performance. For example, Carpendale and Lewis (2006, p. 144)
reviewed the literature and found that a higher percentage of 44-month-
old children in Australia correctly performed the false belief task than
did children in the US and children in Japan. The Australian culture
may value more individualism, independence, and equality, whereas
Japanese children of the same age, who are from a more collective and
hierarchical society, were less often correct than were US children.
Linguistic differences among cultures may also affect acquisition of
social understanding. In studies of cultures whose language does not
typically refer to mental states (Quechuan of Peru, Mofu of Cameroon,
Tolai and Tainae of Papua, New Guinea) children’s ToM performance
lagged behind Western cultures, whose language includes explicit ref-
erences for mental states (for a review see Carpendale & Lewis, 2006,
pp. 144–145).

Cultural Differences in Memory Development

Culture also affects memory, memory development, and skills. Based
on a culture’s values, memory is shaped by what is explicitly taught
or repeatedly modeled. For example, Aboriginal children had bet-
ter visual memory skills in comparison to White Australian children
(Ross  & Wang, 2010). Exemplifying a high contextual learning style,
the Aboriginal children’s increased visual memory skills were presum-
ably influenced by being taught to track beetles and animals in the
desert. Moreover, individualism and collectivism were found to affect
autobiographical memory recall. Chinese adults, who are members
of a collectivist culture, not only rated autobiographical memories as
less important than did their American peers; they also recalled fewer
 Development of Cognitive Processes • 97

personal events (Ross & Wang, 2010). Additionally, Asian participants

asked to describe memories, provided more memories involving other
people, whereas Australian participants provided more personal mem-
ories that did not involve other people. In other words, persons from
diverse cultural backgrounds may attend to, focus on, and recall unique
but culturally relevant information. This cultural bias may influence eye
gaze, social cognition, and learning styles.
Children from different cultures also display different types of socio-
dramatic play (Hwa-Froelich, 2004). Children from Western and more
technologically advanced countries tend to demonstrate sociodramatic
play along fantasy themes (Chen, 2011). For example, Anglo-American
and Korean preschool children were observed during play. The
Anglo-American children demonstrated more social and pretend play,
whereas the Korean children exhibited more educational activity, had
more unoccupied time, or tended to play beside, not with, other chil-
dren (Farver, Kim, & Lee, 1995). Farver and Shinn (1997) hypothesized
that different play styles may be due to the presence of different kinds
of play stimuli in that the Anglo-American preschool had more toys
and the Korean preschool had more educational materials. They video-
taped dyads of Korean and Anglo-American children playing with the
same stimuli (castle, dolls representing a royal family, horses, a carriage,
furniture, and a dragon). In spite of playing with the same stimuli, the
children demonstrated culturally different play behaviors and pragmatic
language. Anglo-American children’s play themes involved a sense of
danger and fantasy, whereas, Korean children’s play included more
everyday activities and family themes. The Anglo-American children
described their own actions, often rejected their partner’s ideas, and
directions. In contrast, the Korean children described their partner’s
actions, used more tag questions, and tended to agree or make polite
requests. Because play assessments may list fantasy play as a higher
developmental skill, it is important for practitioners to be aware that
cultural preferences or beliefs may facilitate more everyday themes than
fantasy themes (Linder, 2008; Westby, 2000).
Farver and colleagues also investigated cultural differences in
mother–child play interactions (Farver & Howes, 1993; Farver & Wim-
barti, 1995). There were differences in beliefs about the value of play. The
Anglo-American mothers felt play was important for children’s educa-
tion and development, but the Mexican mothers believed the purpose of
play was to occupy children’s time. Because of these different play beliefs,
Mexican mothers gave more explicit directions than did the American
mothers. Consequently, the Mexican mothers were less involved in their
children’s play, and their children demonstrated less cooperative pretend
98 • Hwa-Froelich

and symbolic play. Indonesian mothers also believed that play was a way
to occupy children’s time (Farver  & Wimbarti, 1995). However, these
mothers made more suggestions to facilitate pretend play as a strategy
to keep their children occupied for longer periods. In contrast, Indone-
sian mothers, who valued play as an intellectual and social pursuit, gave
explicit directions for task completion. In other words, how play was
valued in each culture affected the ways parents interacted with children
during play. It is important for practitioners to be aware and respectful
of these differences when working with families from diverse cultural
backgrounds. In these situations it may be better to work with parents
on giving explicit directions for more structured or academic play activ-
ities and more suggestions to extend sociodramatic play.

Cultural Differences in Executive Function Development

Cultural preferences for inhibited and regulated behavior may also
affect executive function development. For example, in a comparison of
three preschools across the three cultures of Japan, China, and the US,
Tobin, Wu and Davidson (1989) found that Chinese preschoolers were
expected to inhibit impulses at earlier ages than Western preschoolers.
The Japanese preschoolers were socialized to help regulate each others’
behavior as a way of learning how to cooperate within a large group.
These differences in cultural expectations of preschool behavior may
help children develop the attention, inhibition, regulation, and mem-
ory required for executive function. In a study of preschoolers from
Beijing, China and the US, Chinese children had significantly better
executive function performance than US children on a battery of
executive function tasks (Sabbagh, Xu, Carlson, Moses, & Lee, 2006).
The investigators also measured ToM ability and found no group dif-
ferences. However, executive function performance was predictive of
ToM performance. The authors concluded that cultural differences in
social rearing influenced executive function development, and because
ToM tasks require children to use their executive function skills, execu-
tive function is related to ToM tasks. The findings support the hypoth-
esis that cultural socialization differences strongly influence differences
in attention, inhibition, regulation, and working memory. Because
the Chinese children are socialized to inhibit impulses at earlier ages,
their regulation and inhibition may help them perform at higher levels
of executive function. Executive function is important for ToM skills
because one must attend to nonverbal, verbal, and pragmatic informa-
tion to comprehend social communication. However, linguistic com-
petence and social cognition also predict ToM abilities. Thus, while no
differences were found in social understanding or ToM performance,
 Development of Cognitive Processes • 99

executive function skills predicted higher ToM performance (Sabbagh

et al., 2006).
There is some evidence showing that bilingual children have better
executive function skills than monolingual children. In a study compar-
ing three language groups: native bilinguals; English-speaking, mono-
lingual children; and English speakers enrolled in a second-language
immersion class, the native bilingual children had significantly better
executive function performance than the other two groups (Carlson &
Metzloff, 2008). Their performance was better in spite of having lower
language scores and parents who had received less education and less
income. The authors argued that the bilingual children were “doing
more with less” and that the task of attending to and thinking in two
languages gives bilingual children an advantage in executive function
development (Carlson & Meltzoff, 2008, p. 293). Carlson and Metzloff
(2008) also suggested that bilingual skills may need to be at a high
enough level to enhance metalinguistic and cognitive abilities.
To summarize, cultural values and experiences may affect the devel-
opment of attention, social understanding, memory, and executive func-
tion. Cultural differences in adult-mediated interactions, such as high-
or low-context instructional strategies and values of individualism and
collectivism, can influence what children attend to, remember, and
inhibit. In the case of Natalya, although her general language develop-
ment appeared to be similar across both languages, she may not have
achieved an advanced bilingual level to allow her to develop metalinguis-
tic or cognitive skills to assist her executive function development. While
her processing skills were significantly better in Spanish, her dominant
language, her phonological processing in Spanish was significantly lower
than other Spanish–English bilinguals of the same age. In addition, she
demonstrated weak selective attention, inhibition, and working memory
skills in both languages, regardless of whether the session took place in
quiet or noise, one-to-one individual settings, or large or small groups.
Because of her difficulty with attention and working memory, she was
unable to solve problems, organize her play, or relate in socially appro-
priate ways with her peers and her teachers. In other words, her execu-
tive function and social understanding were negatively affected. Natalya
needed medication to improve her attention as well as support services to
assist her memory and executive function in order for her to learn effec-
tively. With medical intervention, Natalya was able to inhibit distractions
and focus on attending in class. The SLP worked with Natalya during
individual sessions in a quiet room to facilitate English vocabulary learn-
ing, processing of complex directions and questions, and interpretation
of nonverbal and verbal communication of emotions and mental states.
100 • Hwa-Froelich

The classroom teacher moved Natalya to a seat that was closer to the
front, reduced the noise level in the classroom, increased visual sup-
ports for large-group instruction, and provided more opportunities for
Natalya to receive new information through small-group instruction.
The parents continued to facilitate Natalya’s Spanish-language devel-
opment through shared storybooks. The SLP and teacher provided
examples of different levels of questions that increased in complexity
to help the parents facilitate inferential language and perspective taking
relative to the story characters. Natalya was able to attend during class-
room instruction and to interpret nonverbal and verbal communication
more accurately at school. The parents reported that Natalya was able to
answer more complex questions about the stories they read at home and
were pleased with her progress at school.

DISCUSSION QUESTIONS
1. How does neurological development relate to attention and
memory development?
2. In what ways does inhibition or self-regulation affect attention?
3. What is memory?
4. How do explicit and implicit memories differ?
5. Compare and contrast autobiographical, semantic, procedural,
and episodic memory.
6. How do children demonstrate memory recall initially?
7. Why are attention and memory important for executive function?
8. How does culture affect children’s attention and memory?

INSTRUCTIONAL RESOURCES
Videos
A Selective Attention Test: www.youtube.com/watch?v=vJG698U2Mvo
Brown, S. (2008). Stuart Brown: Playing is more than just having fun. Retrieved
from www.ted.com/talks/stuart_brown_says_play_is_more_than_fun_it_
s_vital.html
Compare and Contrast Implicit and Explicit Memory: www.youtube.com/
watch?v=o-W6TDYi0Cw
Dr.  Siegel—On How You Can Change the Brain: www.youtube.com/
watch?v=i4tR5Ebc4Mw
Executive Function: www.youtube.com/watch?v=efCq_vHUMqs
Types of Memory: www.youtube.com/watch?v=mjzhcNeL0G0
 Development of Cognitive Processes • 101

Unexpected Contents video. Retrieved from www.youtube.com/watch?v=8h

LubgpY2_w
Unseen displacement and explaining action, Sally-Anne story. Retrieved from
www.youtube.com/watch?v=QjkTQtggLH4

Websites
Brain Rules: www.brainrules.net/attention
Brain Tools: www.mindtools.com/memory.html
Center on the Developing Child, Harvard University: http://developingchild.
harvard.edu/resources/multimedia/videos/inbrief_series/inbrief_execu
tive_function/
Human Memory: www.human-memory.net/
National Center for Learning Disabilities: www.ncld.org/types-learning-dis
abilities/executive-function-disorders/what-is-executive-function
Psychology Today: www.psychologytoday.com/basics/memory

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 5
SOCIAL COMMUNICATION DEVELOPMENT
Deborah A. Hwa-Froelich

The child’s behavior influences the caregiver’s responsiveness which

influences the child’s development. The child’s developmental outcome
is determined by the mutual interaction or transaction of the child and
the environment.
—Wetherby (1991, p. 255)

The values of a culture influence the communicative interactions that

caregivers have with their children. Children are socialized into their
culture by the ways in which caregivers and peers talk to them and
guide them to participate in conversations.
—Crago and Eriks-Brophy (1994, p. 44)

LEARNING OBJECTIVES
Readers will
1. Be able to describe developmental skills that are related to social
communication development.
2. Be able to define primary and secondary intersubjectivity and
how these skills relate to the social communication develop-
ment.
3. Gain knowledge about nonverbal, verbal, and pragmatic commu-
nication development and their relationship to social communi-
cation development.

108
 Social Communication Development • 109

4. Be exposed to how sociocultural factors such as poverty, the

hierarchy of dependence and interpersonal relationships, and
linguistic diversity, affect social communication development.

Shelly lived in a two-parent family from a low-income background.

Both parents were Caucasian and had not graduated from high school.
Her mother suffered from diabetes as well as limited vision and was the
primary caregiver. The father worked long hours during the week as a
laborer and rarely interacted with Shelly.
The county health department had referred Shelly and her mother
for early intervention services with concerns about failure to thrive due
to Shelly’s overall developmental delays and lack of weight gain. During
the initial home visit, the early intervention team observed a home envi-
ronment that limited Shelly’s stimulation and exploration. The furniture
and floor space were covered with objects or papers, the curtains were
closed, and the lighting was poor. Shelly spent most of the day in a play-
pen in a darkened room with no toys and little social interaction with
adults. The mother reported feeling afraid to pick up or hold her daugh-
ter. She felt the only safe place for her daughter was in the playpen. She
was concerned about her daughter’s loss of weight and wanted to know
how to feed her so that she would be healthy.
The initial assessment occurred at 9 months of age at which time
Shelly avoided or did not initiate eye contact, her interests were directed
toward objects more than toward people, and she did not respond to
her name being called. Cognitively, Shelly demonstrated curiosity,
fleeting attention with toys, and few schemas when interacting with
objects. Although her play skills were developmentally delayed in terms
of focused attention, play complexity, and functional use of toys, she
demonstrated some cognitive flexibility when trying to manipulate
cause-and-effect toys. Expressively, Shelly used limited gestures such
as reaching for objects, but no other symbolic gestures were observed.
The only intentional communication observed was protesting. Shelly’s
mother reported that Shelly had made some sounds earlier but stopped
making these sounds and now was quiet most of the time. Few vocaliza-
tions were observed during the assessment, and the interaction between
Shelly and her mother involved little face-to-face eye gaze or verbal
communication.
The team concluded that Shelly was at risk of failure to thrive because
of the lack of social interaction she was receiving from her parents.
While her parents loved her, they lacked the knowledge and confidence
to provide collaborative, contingent social and communicative interac-
tions. Shelly needed these kinds of social interactions to develop a close,
110 • Hwa-Froelich

secure relationship with her parents to enable her to be socially moti-

vated to interact and communicate and to be able to regulate her emo-
tions to develop sustained and focused attention. Her parents needed
support to help them develop a positive relationship with Shelly and
learn how to mediate and facilitate Shelly’s social, emotional, communi-
cation, and cognitive learning potential.
Shelly’s case demonstrates the importance of early face-to-face com-
municative interactions in infants’ survival and development. Although
Shelly was born without any health problems or concerns, she was at
risk of failure to thrive and developing significant delays across multi-
ple developmental domains because of her parents’ lack of confidence
and knowledge in caring for her. Her profile is an example of how envi-
ronmental variables can result in unique and dynamic developmental
outcomes. Dynamic systems theory, as explained in Chapter  1, helps
provide a theoretical understanding for such diversity in the develop-
ment of social communication competence.
As defined in Chapter  1, social competence consists of having the
knowledge, skills and behaviors to fulfill one’s needs and meet his or
her expectations in social interactions (Goldstein, Kaczmarek, & Eng-
lish, 2002). To be a competent communicator during social interactions,
one must know, interpret, and demonstrate socially appropriate behav-
iors as well as have adequate oral language skills (Kaczmarek, 2002). As
discussed in Chapters 3 and 4, social competence is influenced by (a)
attachment, (b) the ability and desire to share experiences with others,
(c) regulation of emotions and attention, and (d) the ability to recall past
events and social knowledge to predict, plan, and guide behavior during
social interactions (Hwa-Froelich, 2012a). When caregivers are sensitive
and accurate in reading their infants’ behaviors and meeting their needs,
a close, trusting relationship develops. Through socially mediated con-
versations with their parents, infants learn communication behaviors
and refine their communication to facilitate the likelihood in achieving
their goals. For example, infant crying results in a caregiver coming to
intervene or infant cooing results in caregivers smiling and attending to
the infant. Infants learn to trust and depend on persons who most reli-
ably meet their needs, forming a secure attachment with them.
These relationships between communication and outcomes are
learned in specific culturally influenced contexts in which certain
behaviors may be expected and associated with consequences in par-
ticular places and times. The communicative functions and social
rules of communication that children learn are dependent upon social
interactions with adults as explained by social interaction theorists
 Social Communication Development • 111

in Chapter 1. Initially, infants are exposed to and share emotions and

experiences with their caregivers and siblings. Needs, emotions, inten-
tions, and the desire to share experiences motivate infants to com-
municate. These early social communication skills are associated with
later language competence and academic achievement (Greenwood,
Walker, & Utley, 2002; Hart & Risley, 1995). In Shelly’s case, she had
not developed a secure attachment to her parents, and with the lim-
ited social interaction she had little opportunity to share emotions and
experiences or learn how to communicate socially. Using communica-
tion instrumentally to share emotions, needs, wants, and experiences
and developing knowledge about mental states and mental actions are
the major components of social communication competence. This
chapter includes discussions about the development of social com-
munication. Attachment and social and emotional development are
discussed in Chapter 3.
The necessary skills needed for effective social interactions include
the ability to (a) process, interpret, and express nonverbal and verbal
communication; (b) use communication for a variety of functions; (c)
predict and plan communication for future social interactions and con-
texts; and (d) flexibly respond to a dynamically changing communica-
tive interaction (Hwa-Froelich, 2012a). In other words, one must be able
to interpret and express through facial expressions, gestures, posture,
proximity, tone of voice, and vocal intensity, using appropriate verbal
content and pragmatic conventions. To be able to demonstrate these
skills, one must have a strong foundation in receptive and expressive
language competence, and pragmatic language competence, defined
by Ninio and Snow (1996) as “the appropriate, effective, rule-governed
employment of speech in interpersonal situations” (p. 4).
Other cognitive skills are also involved such as executive function,
working memory, selective attention, and the ability to switch atten-
tion. In addition, one must develop social cognition (the knowledge
that events cause people to feel particular emotions and emotions cause
people to act in certain ways), and social understanding which involves
what many refer to as Theory of Mind (ToM), the perception of and
understanding of one’s and others’ mental states (for a review of the his-
tory of theoretical terminology see Carpendale  & Lewis, 2006). These
cognitive skills are described in Chapter  4. This chapter focuses on
typical social communication development of (a) intersubjectivity and
nonverbal communication development, (b) speech and language devel-
opment, and (c) pragmatic language development. The final section of
this chapter describes factors affecting social communication competence.
112 • Hwa-Froelich

INTERSUBJECTIVITY AND NONVERBAL

COMMUNICATION
Infants expect developmentally appropriate care and depend upon
their caregivers to sensitively read their behaviors and respond con-
tingently and accurately to their cries for help (Lewis, 1997). To share
their emotions, needs, and wants with others, infants must learn how
to initiate and maintain interaction with another person. This process
begins during face-to-face interactions sharing feelings and mental
states. As described in Chapter 4, this process involves primary inter-
subjectivity (Trevarthen, 1979, 1992). This drive for social interaction
and intentionality facilitates the sharing of emotions and communi-
cation between a caregiver and an infant so that the infant feels felt.
If the caregiver accurately reads and interprets an infant’s emotions,
amplifies positive emotional states, and assists the infant in regulat-
ing or reducing negative emotional states, the caregiver is successful
in interpreting and facilitating the infant’s communicative intentions.
Through primary intersubjectivity, caregivers help children learn to
identify their own emotions and eventually how to identify and pre-
dict others’ emotions. This ability to recognize or predict self and other
people’s emotions, intentions, or thought is called the development of
social understanding or Theory of Mind (ToM) as discussed in Chap-
ter 4 (Baldwin & Moses, 1994; Baron-Cohen, 1997; Butterworth, 1994;
Carpendale & Lewis, 2006).
Social competence and socially competent communication behav-
iors emerge from the developmental foundations of social understand-
ing and intersubjectivity and are affected by individual (endogenous)
and environmental (exogenous) factors (for a review see Hwa-Froelich,
2012b). Initially infants are motivated by egocentric desires and needs.
Although infants are largely egocentric, they typically prefer interac-
tions with people rather than objects, which may indicate a human
proclivity to perceive the mental/emotional states of others (Legerstee,
2005). To meet their infants’ biological needs of hunger and discomfort,
caregivers interact through primary intersubjectivity, communicating
through positive facial expressions, nurturing touch, and a soothing
tone of voice, which helps infants begin to interpret facial expressions
and vocal tones associated with different emotions.
Caregivers communicate about their own and others’ emotions,
expectations, and intentions. They describe their and others’ social cog-
nition about objects, actions, and emotions. By 5 to 6 months of age,
infants develop joint attention (e.g., look at what others look at and get
others to look at what they are looking at) by following the gaze of others
 Social Communication Development • 113

to see what others see and follow a line of regard when others point.
This stage is called secondary intersubjectivity or sharing mental/emo-
tional states involving an object (Legerstee, 2005). Infants and toddlers,
between 9 and 15 months of age, learn to co-regulate their interactions
with others by sharing mental/emotional states and social referencing,
and directing and sharing joint attention with caregivers (Baron-Cohen,
1997; Bruner, 1999; Legerstee, 2005). Children begin to perceive and
infer what object, event, or being, someone else sees, and eventually
they learn that other people may have different thoughts, perspective,
and knowledge than they do about the same objects and events, or what
was described as inter-ToM in Chapter 4.

Nonverbal Communication Development

In addition to developing intersubjectivity and social understanding,
social communicative competence is dependent upon the development
of communicative competence. For typical communication development,
mothers must have received adequate prenatal and postpartum treat-
ment. Healthy prenatal care includes adequate nutrition and no exposure
to or intake of chemical substances that would harm the fetus (toxins,
drugs, alcohol, or nicotine). Healthy infants would have no neurological
symptoms, hearing loss or recurrent ear infections, or oral motor anoma-
lies such as cleft palate, all of which would affect communication devel-
opment. However, not only is it important for infants to have received
adequate prenatal care and be neurologically and physically intact; social
interaction theorists also believe infants must be exposed to language-rich
social interactions to develop perception, processing, and accurate pho-
nological processing and expression, as well as receptive and expressive
language competence (Vygotsky, 1934/1986). When children receive
inconsistent or inappropriate social interactions or their communication is
misinterpreted, they are at risk of exhibiting dysfunctional or delayed com-
munication development and social-emotional relationships (Beck, 1996;
Coh, Matias, Tronick, Connell,  & Lyons-Ruth, 1986; Solantus-Simlua,
Punamaki, & Beardslee, 2002; Sroufe, 1997). The amount and quality of
caregiver verbal stimulation are strongly correlated with children’s com-
munication abilities in children being raised by their biological parents
and for children attending a child care center (Clarke-Stewart, 1973;
National Institute of Child Health and Human Development Early Child
Care Research Network [NICHD], 2000; Stafford & Bayer, 1993).
Communication involves not only comprehension and expression of
verbal messages, but also includes nonverbal components such as facial
expressions, tone of voice, gestures, and postures (Anderson, 1998;
Nowicki  & Duke, 1994). For interpretation of mental and emotional
114 • Hwa-Froelich

states during social interactions, it is important to accurately interpret

and express facial expressions, gestures, and tone of voice (Chiat & Roy,
2008). Facial expressions and tone of voice make up approximately 55%
and 38%, respectively, of all nonverbal communication, which is about
93% of all nonverbal communication (Koneya & Barbour, 1976).
It is through face-to-face interactions that children learn to associate
nonverbal aspects of communication with social and emotional mean-
ing (Beer & Ochsner, 2006). For example, infants associate and inter-
pret facial expressions and tone of voice to determine how they should
react to ambiguous situations or stimuli (Siegel, 1999; Walden & Ogan,
1988). Interpretation of facial expressions and tone of voice develop
at about the same time. Caron, Caron, and Myers (1982) studied 108
infants between 18 and 30 weeks old and found that 30-week-old infants
discriminated between happy and surprised facial expressions. Later, at
about 1 year of age, infants altered their behavior toward a false visual
cliff based on their mothers’ facial expressions of joy or fear. This change
in behavior indicates the infants inferred different meanings from dif-
ferent facial expressions and adjusted their behavior accordingly (Sorce,
Emde, Campos, & Klinnert, 1985).
After children develop language to label emotions, their discrimina-
tion and understanding can be measured through receptive and expres-
sive language. Camras and Allison (1985) asked 109 children between
the ages of 3 to 8 years to identify characters’ emotions in short stories
by selecting an emotional label or facial expression for happy, sad, dis-
gust, and fear. The 3-year-olds were able to identify emotions at an aver-
age level of 82% accuracy using labels or selecting facial expressions,
and the 8-year-old children were more accurate than were younger chil-
dren. Thus, accuracy improved with age. Similar to facial expressions,
discrimination and recognition of vocal emotions begin to develop by
5 months of age (for a review see Campanella & Belin, 2007) and accu-
racy improves with age. Rothman and Nowicki (2004) recruited 81 chil-
dren between the ages of 4 and 12  years and asked them to identify
the emotion expressed by adults and children stating the same sentence
in happy, sad, angry or frightened voices. The 4-year-old children had
an average error score of 12.1 of a total 24 responses, with a standard
deviation (SD) of 5.9, whereas the 8-year-old children had an average
error score of 7.1 (SD = 5.3; Rothman & Nowicki, 2004, p. 76). Thus, the
8-year-old-children made fewer errors than did the 4-year-old-children
when interpreting different emotional vocal tones.
There may also be gender differences in nonverbal communication
performance. McClure (2000) conducted a meta-analysis of 104 studies
 Social Communication Development • 115

that used identification of facial expressions including infants, children,

or adolescents up to the age of 18 years. McClure reported that females
were more accurate than were males and that older subjects performed
better than did younger subjects. The female advantage was found across
all age groups regardless of the measures administered, the age reflected
in the face stimuli, and the gender of the investigators. Gender differences
were also found with 50 second-born children between the ages of 33 and
40 months who were asked to label emotions expressed by puppets act-
ing out stories (Dunn, Brown, Slomkousky, Tesla, & Youngblade, 1991).
Girls were better able to label emotions than were boys. Because all chil-
dren were second-born children, gender and birth order may influence
reading of facial expressions and tone of voice. A younger sibling has the
advantage of watching emotional interactions of their older sibling and
their parents, an advantage the oldest sibling does not experience.
Gesture comprehension and expression occurs about the same time
in development. Deictic gestures such as reaching, giving, pointing,
and showing, develop between 10 and 12 months of age (Capone  &
McGregor, 2004). Representational gestures, such as using a cupped
hand to represent a glass or cup for drinking, develop around 12 to 15
months of age (Capone & McGregor, 2004; Crais, Watson, & Baranek,
2009). These gestures develop at approximately the same time that early
communicative functions develop, which is discussed in the subsec-
tion on pragmatic language development. Table 5.1 depicts the parallel
development of nonverbal and pragmatic communication.

SPEECH AND LANGUAGE DEVELOPMENT

This section does not include specific developmental milestones but
provides a brief general overview of speech and language develop-
ment. Speech and language development follow a predictable pattern.
Several studies have documented monolingual English developmental
milestones for vowel, consonant, and consonant cluster productions.
Before infants are able to talk, their prelinguistic development moves
from reflexive crying and vegetative sounds at birth to 2 months, to
cooing and laughter from 2 to 4 months of age, vocal play from 4 to 6
months, canonical babbling around 6 months of age or older, and even-
tually to jargon and meaningful speech from 10 to 18 months of age
(Bauman-Waengler, 2009; Ferguson, Menn, & Stoel-Gammon, 1992).
Production of phonemes begins with vowel then consonant produc-
tion. Labial consonants /m, b/ are the first to develop followed by front
116 • Hwa-Froelich

Table 5.1 Nonverbal and Pragmatic Language Development

Nonverbal Development Pragmatic Development
0–8 months Discriminates facial expressions Perlocutionary stage: at-
and vocal tones tends/responds to stimuli,
anticipation, initiates behavior
to continue activity, shows self,
changes behavior to achieve
goal
6–12 months Interprets facial expressions to Illocutionary stage (proto-
alter behavior imperatives and protodeclara-
tives)
Referencing
10–12 months Develops deictic gestures
13–24 months Develops representational and Locutionary stage, speech acts
symbolic gestures develop
3–4 years Labels emotions in facial
expressions/vocal tones

Source:
Adapted from Westby (2012).

and back plosives, such as /p, t, k/. More plosives are articulated followed
by fricatives such as /f, s/ (Bauman-Waengler, 2009). By the age of 6 years,
most children accurately produce more than 90% of all vowels, conso-
nants, and consonant cluster productions (James, van Doorn, & McLeod,
2002). Children who are 4 years old and older typically demonstrate at
least 90% intelligibility in all productions (Gordon-Brannan, 1994).
Predictable simplification processes are evident in children’s speech
but inhibition of these processes develops over time. For example, sylla-
ble reduplication, such as dada for daddy, occurs before 1 year of age but
is no longer used by 1.6 to 1.9 years of age (Bauman-Waengler, 2009).
Deletion of final consonants (two car for two cars) is no longer present
by age 3, and weak or unstressed syllable deletion (ocpus for octopus)
disappears by age 4. Cluster reduction (srong for strong) and epenthe-
sis (insertion of sounds such as athulete for athlete may continue to be
evident in 8-year-old children (Bauman-Waengler, 2009). Adultlike
phonological development tends to appear between 5 to 8 years of age
(Bauman-Waengler, 2009; James, 2001).
Comprehension begins at the single word level and progresses rapidly
to three and four word sentences. Initially around 8 to 12 months of age,
infants understand a few single words in the context of daily routines
 Social Communication Development • 117

(Chapman, 1978; Edmonston,  & Thane, 1992). These would include

words like mama, bottle, or binkie. By 1 to 1.5  years of age, children
begin to understand words outside of the context with some contextual
support. After 18 months of age, children begin to understand words
for objects that are not in the immediate context and some two-word
combinations. Then by age 2 to 3, children begin understanding three-
or four-word sentences based on past experiences and the context of the
situation (Chapman, 1978; Edmonston & Thane, 1992).
Meaningful linguistic productions begin around 10 to 18 months
of age with the consistent use of words to represent objects. Nouns,
pronouns (me, you), function words (that), and relational words
(all gone) are acquired earlier and in larger numbers than are verbs
(Banajee, DiCarlo,  & Stricklin, 2003; Nelson, 1973). Children typi-
cally develop a 20 or more word vocabulary by approximately 18 to 24
months of age, at which time they begin to use multi-word utterances
and decontextualized language that is talking about objects, persons,
and events not in the present context (for a review see Owens, 2012).
Mean length of utterance increases with vocabulary knowledge and
usage. Utterance complexity develops over time as well with the
expression of noun and verb phrases and dependent clauses. Explicit
verbal talk about means–end or problem solving occurs at 4 years of
age and becomes internalized at later ages (Winsler, Carlton, & Barry,
2000). Adultlike oral language competency is typically achieved by
age 5 years (Owens, 2012).
Inflectional morpheme acquisition follows a typical progression. Ini-
tially children learn morphemes in the following order:
1. present progressive –ing
2–3. prepositions in and on
4. plural –s
5. irregular past tense (came, broke)
6. possessive –s
7. uncontractible Be verb (Dogs are nice)
8. articles a and the
9. regular past tense –ed
10. regular third-person noun–verb agreement –s (The dog walks)
11. irregular third-person noun–verb agreement (he has, does)
12. uncontractible auxiliary Be verb, (Who is here? I am)
13. contractible copula (It’s my car)
14. contractible auxiliary Be verb (Daddy’s going too) (Brown, 1973).
All are typically acquired by 50 months of age. Refer to Table  5.2 for
operations of reference and semantic relations.
118 • Hwa-Froelich

Table 5.2 Operations of Reference and Semantic Relations

Operations of Reference Examples Intent
Nomination There dog There’s a dog.
Recurrence More cookie I want more cookie.
Negation
Denial No hit I don’t hit.
Rejection No bed I don’t want to go to bed.
Nonexistent All gone The food is gone.
Semantic Relations Examples Intent
Action + agent Doggie run The dog is running.
Action + object Eat food I am eating food.
Action + locative Go in I go in.
Agent + object Mommy hat Mommy is wearing a hat.
Entity + locative Bear chair The bear is in the chair.
Possessor + Possession Baby shoe This is the baby’s shoe.
Entity + attributive Big shoe The shoe is big.
Demonstrative + Entity That chair Not this chair, that chair.

Source:
Adapted from Brown (1973).

Brown (1973) also described semantic and syntactical development in

stages of sentence types and structure. Stages coincide with morpholog-
ical development and the mean length of the number of morphemes in
utterances (MLUm). Stage I typically occurs between the ages of 15 and
30 months when children have a 50- to 60-word vocabulary and are just
beginning to link words together. These two-word utterances could be
operations of reference and/or demonstrate semantic relations. During
Stage II, which occurs between 28 and 36 months of age, the first four
morphemes (-ing, in, on, plural –s) are acquired and the children’s aver-
age MLUm is 2.25 (Brown, 1973). Stage III, which occurs around 36 to
42 months of age, involves the acquisition of the next three morphemes
(irregular past tense, possessive –s, uncontractible Be) and a MLUm of
approximately 2.75. During Stage IV, children, typically between 40 and
46 months of age, express an average MLUm of 3.5 and acquire mor-
phemes 8, 9 and 10 (articles a and the, regular past tense, third-person
noun–verb agreement –s). Finally, Stage V occurs approximately
between 42 and 52 months of age, during which the children acquire the
last morphemes (irregular noun–verb agreement, uncontractible auxil-
iary Be verb, contractible Be copula, and auxiliary Be verb) and achieve
an average MLUm of 4.0 (Brown, 1973).
 Social Communication Development • 119

PRAGMATIC LANGUAGE DEVELOPMENT

Pragmatic development and refinement continues across the lifespan.
However, in this section, development of pragmatic language during a
child’s early years through school age is the focus. Emergence of prag-
matic language development occurs in three stages: (a) perlocutionary,
(b) illocutionary, and (c) locutionary (Bates, 1976). Research in prag-
matic development has covered several topics. The purpose of this chap-
ter is to focus on the skills that develop during childhood, not all aspects
of pragmatic language. These include (a) intentionality, (b) speech
acts, (c) politeness rules, and (d) rules associated with conversational
exchanges.

Intentionality
The perlocutionary stage may range from the ages of 0 to about 9 months
of age. During this stage, the infant’s behavior, such as crying or smiling,
may or may not be intentional or goal directed. However, some parents
may interpret and verbally react to their vocalizations or behavior as
intentional (Westby, 2012).
Following the perlocutionary stage, the illocutionary stage tends to
occur between 9 to 13 months of age. During this stage, infants begin
to demonstrate behaviors that are goal directed or intentional. These
behaviors include attention-seeking behaviors such as showing, reach-
ing, pointing, and vocalizations as well as using eye gaze to check for
parent attention. Bates (1976) describes some of these early attempts as
protoimperatives (attempts to get an adult to do something) and proto-
declaratives (attempts to direct an adult’s attention). Protoimperatives
are behaviors that infants use to initiate a behavioral request and proto-
declaratives are behaviors infants use to initiate joint attention (Bates,
1976).
To move from a perlocutionary stage to the illocutionary and locu-
tionary stages, children must learn how to reference persons, objects,
or actions (Westby, 2012). Referencing is used to direct or hold another
person’s attention. For example, parents often place objects within their
infant’s field of vision and talk about the object. Around 8 months of
age, infants begin to look for the object and check and follow the adult’s
line of regard. By 12 months of age, if infants cannot see the object, they
will check the parent’s line of regard and search for the object. About the
same time, referential gestures, such as pointing and reaching, develop
concurrent with word use in emerging pragmatic language development
(Capone & McGregor, 2004). During this developmental stage, parents
begin to ask what and where questions such as “What is it?” or “Where
120 • Hwa-Froelich

is it?” This transactional interaction reinforces children’s bids for joint

attention and behavioral requests, and facilitates turn taking and longer
conversational exchanges.
Infants begin to demonstrate prelinguistic behaviors of self-regulation,
social interaction and joint attention (Wetherby  & Prizant, 2002).
Table  5.3 lists the types of behaviors for each category and includes
gestures, movements, and vocalizations that communicate intention.
These behaviors are influenced by the caregivers or by family members’
responses, which are culturally influenced. These cultural factors are
discussed in the subsequent section on factors affecting social commu-
nication development.

Speech Acts
Speech acts, or using speech for specific functions, can be organized
according to developmental stages. Speech can be used functionally
for personal or interpersonal functions. Halliday (1975) suggested that
speech can be used internally for memory, problem solving, or devel-
opment of ideas. Interpersonal functions are speech acts in which indi-
viduals use words to cause action (Austin, 1962). Speech acts include
using language to make promises, declarations, directions, questions,
comments, threats, warnings, suggestions, and many other actions

Table 5.3 Early Prelinguistic Communication of Intention

Behavioral Regulation Social Interaction Joint Attention
Request specific object Greet (notes initiation or Transfer (gives object)
termination of
activity)
Request object Request social routine (initi- Comment on object
ates game or routine)
Request action Show off (for attention) Comment on action or
event
Protest action Call (attract attention) *Request information
Acknowledgment (indica- *Clarification
tion communication was
received)
Request permission (seeks
approval to do something)
Personal (shows mood or
feelings)

*Typically appears in locutionary stage.

 Social Communication Development • 121

(Searle, 1969). For example, saying “help” can cause an adult to help a
child complete an action like procuring a desired object that is out of the
child’s reach. To effectively use speech for action, the speaker must have
certain kinds of knowledge:
• Knowledge of the linguistic structures used for specific func-
tions.
• Social knowledge of appropriate contexts for different
speech acts.
• Social cognition of the most appropriate linguistic speech act
form to use with a particular speaker based on the speaker’s per-
sonal characteristics (i.e., register; McTear  & Conti-Ramsden,
1992).
Following the perlocutionary and illocutionary stages and prelinguistic
intentional communication, toddlers, around 13 to 18 months of age,
begin to understand and express words. Bates (1976) called this the
locutionary stage. During this stage, children learn to use words to rep-
resent objects, attributes, and actions. They also begin to use words as a
tool to get their wants and needs met. Initially, infants and toddlers view
the world from an egocentric viewpoint, and as their linguistic skills
mature, they develop more refined and advanced functions that are cul-
turally influenced. Each culture defines what behaviors are appropriate
or inappropriate and what is polite or impolite for speech acts and con-
versational exchanges.
One of the first speech acts children learn is requesting (Bruner,
1983). Bruner described three kinds of responses in emerging pragmatic
language development: (a) requests for objects, (b) requests for others’
participation in an interaction, and (c) requests for help to achieve a
goal. The success of the interaction is dependent on the caregiver’s abil-
ity to accurately interpret the child’s request in order to respond in the
way the child expects or desires. Requests for objects that are within
sight or close to the child develop prior to 12 months of age. Requests
for objects outside of the immediate context develop around 18 months
of age (Westby, 2012). This development coincides with implicit social
understanding development, referential talk about objects out of con-
text in language development, and use of words with referential ges-
tures. Embedded requests such as “Would you get me a drink?” emerge
around the age of 3 years (Owens, 2012; Read & Cherry, 1978, as cited
in McTear & Conti-Ramsden, 1992). Children become more implicit in
their speech acts by 5 or 6 years of age and give hints related indirectly
to their goal (“She’s not playing with me. She’s watching my brother”).
122 • Hwa-Froelich

As children mature, they begin to provide reasons for requests that may
involve the other person’s desires or rights. (“Dad, it’s my turn to ride
the bike. He has to share”). By age 8 years, they also begin to understand
how requests may emotionally affect the other person and communi-
cate the cost–benefit relationship of the request and compliance or offer
options with their requests (“If you help me pick up the toys, I’ll let you
ride my bike”; McTear & Conti-Ramsden, 1992; Owens, 2012).
Some research on other speech acts such as commissives, expressives,
and explanations has been summarized by McTear and Conti-Ramsden
(1992). Commissives or promises are expressed as early as age 5 years
(“I promise to be good”), but it is not until 9 years of age that children
seem to understand the difference between promises and predictions
(“You’re going to get in trouble”). Expressives, or routine communica-
tion such as “I’m sorry,” “Please,” and “Thank you” are often taught as
early as 2 years old, but children do not appear to comprehend the role
of these acts until they are older (McTear  & Contin-Ramsden, 1992).
Although commissives and expressives are acquired at older ages, 3- to
4-year-old children were found to provide explanations when seeking
help from the listener and when the listener’s actions were unwanted
(“Mommy, please use the pink ribbon because it matches my dress”) and
indirect requests by age 5 (Owens, 2012).
Other research has provided evidence that young children use repair
and revision strategies in cases of communication breakdown. Children
as young as 2 years of age demonstrated appropriate responses to different
clarification requests (McTear & Contin-Ramsden, 1992). Older children
with more advanced linguistic abilities (Brown’s Stages II and III) developed
a variety of repair and revision strategies (McTear  & Contin-Ramsden,
1992). Owens (2001) reported that the predominant repair strategy for
children younger than 9 years of age is repetition (“I said I want the blue
one!”), but 9-year-olds are able to perceive communication breakdowns
and provide definitions of terms, increased context, as well as talk about
how to repair the breakdown in communication (“I don’t want to talk to
my mom on the phone because I’ll start crying because I miss her”).
In addition, children demonstrate knowledge of speech and language
characteristics associated by a person’s role in life as young as 4 years of
age. Children will imitate vocal pitch, loudness, and politeness registers
as well as linguistic utterances associated with dramatic roles during
symbolic play scenes (Owens, 2012). Initially, toddlers and preschoolers
will use motherese when pretending to be a mother or simplified one-
to two-word utterances when pretending to be a baby or a toddler. As
children mature, they begin to take on communication styles for other
 Social Communication Development • 123

characters such as pretending to be a doctor, a teacher, a police officer,

or a firefighter.

Politeness Rules
How to display appropriate politeness is influenced and judged by one’s
cultural group, which is also influenced by socioeconomic factors.
Politeness rules are also affected by context, age, and conversational
partners. Initially, as infants and toddlers, children are developing close
relationships with their caregivers. While toddlers play alongside other
children, they are not developing close personal friendships with other
children. It is not until later preschool ages, that children have devel-
oped the linguistic maturity, self-regulation, and the ability to think
about someone else’s point of view to begin to form friendships with
peers (Goldstein & Morgan, 2002).
Linguistic interactions and participant behaviors are largely affected
by the context of the interaction (Abbeduto & Short-Meyerson, 2002).
Utterances are expected to be appropriate toward the goal or intent and
contingent to the interaction. Participants are also expected to appro-
priately and accurately interpret responses and information relative to
the goal and/or intention. Abbeduto and Short-Meyerson (2002) sum-
marize research that provides evidence of young children adjusting the
length and complexity of their utterances for younger children, provid-
ing more detail to someone who may not have knowledge of the event,
and increasing their use of polite forms when talking with adults or less
familiar participants. They conclude that these adjustments are made
based on children’s past experiences with the participants, as well as
their beliefs about the age-related differences in linguistic ability and
“authority” (Abbeduto and Short-Meyerson, 2002, p. 37).
Indirect requests, inferences, and use of ambiguous language develop
during the school-age years (“I can’t see the book”; “That dog isn’t very
friendly”; “It’s raining cats and dogs”). Owens (2012) summarizes prag-
matic development during the school-age years. He reports that chil-
dren recognize nonliteral meanings in indirect requests and consider
others’ intentions by age 8. Between 16 and 18 years of age, children use
sarcasm, double meanings (politics = many bloodsucking insects), and
metaphors (“My heart is broken”), and discriminate between others’
and their own perspectives. Thus, pragmatic development continues
to develop and refine across childhood into adulthood. All pragmatic
behaviors, intentionality, speech acts, repair strategies, and politeness
rules, are expected, self-monitored, regulated, and expressed dynami-
cally during conversational exchanges.
124 • Hwa-Froelich

Conversational Exchanges
Grice (1975) proposed four maxims that are needed for cooperative
conversation. These maxims are related to qualitative judgments of
quantity, quality, relation, and manner.
• Contributions should be informative as needed for the exchange.
• Contributions should be true based on adequate evidence.
• Contributions should be relevant.
• Contributions should be clear, brief, and orderly.
Grice also described how these maxims could be used to mean or impli-
cate unspoken messages by using conventional and conversational
implicature (McTear & Conti-Ramsden, 1992). Conventional implica-
tures are meanings related to an utterance that are unspoken because
of the nature of cooperative maxims. For example, if a speaker states
that he or she was studying abroad for the summer semester, according
to the maxim of quantity and relevance, the speaker provided a limited
amount of relevant information. The conventional implicature could be
that the person was also in a different country to study abroad. Conver-
sational implicature, on the other hand, is when an indirect statement
is communicated to infer or implicate another meaning. For example, if
Speaker A asks Speaker B, “Will you be able to come to my wedding?”
Speaker B could use conversational implicature to avoid hurting Speaker
A’s feelings by saying, “I’m sorry. I  was planning on studying abroad
for the summer.” This response meets the definition of conversational
implicature in the following ways:
1. It infers that the wedding date and her duration of studying
abroad are at the same time.
2. Speaker B could cancel the statement by adding more informa-
tion (“I  think I  may return from studying abroad in time for
your wedding”).
3. The statement is attached to the semantic content but not the
linguistic form.
4. The statement is calculable and cooperative.
5. It is nonconventional in that the meaning is beyond what is spo-
ken (“I am not sure whether I can attend”).
6. It is indeterminate in meaning if the same statement was spoken
in a different context and time (such as spoken to share infor-
mation about what one did over the summer).
The cooperative maxims and use of implicature in conversation can
result in an infinite number of combinations and inferences. Based on
 Social Communication Development • 125

one’s history and experience, individual variability in comprehension

and use of these strategies can be dynamic and uniquely individual.
The study of conversational discourse also includes such strategies
as taking turns, and topic initiation, maintenance and closure. Verbal
responding increases between 2 and 3 years of age, a 3-year-old can take
two to three turns during a conversation as compared to about 50% of
5-year-olds who can talk about a topic through approximately 10 to 12
turns (Owens, 2012). Similarly, initiating, maintaining, and discontinu-
ing topics develop as children gain linguistic competence. Toddlers have
a limited ability to maintain a topic beyond a question and response
format such as “What do you want to do, go outside or read a book?”
However, 3- to 4-year-olds can maintain the topic about 75% of the time
(Owens, 2012). Yet, by age 3.5 years, most of the children’s utterances
are on an initiated topic. They also monitor and change informational
exchanges based on what they determine their listener knows or does
not know. Mental state vocabulary increases between 4 and 7 years of
age (Moore, Harris,  & Patriquin, 1993). School-age children are able
to initiate, maintain, take numerous turns, and stop or switch topics in
conversation (Owens, 2012).

FACTORS AFFECTING SOCIAL

COMMUNICATION COMPETENCE
Several factors can influence social communication styles and abili-
ties. As mentioned previously, socioeconomic status (SES) and culture
are some of the factors that are discussed in this chapter. In addition,
communication disabilities such as language impairment, autism,
attention-deficit disorders, and social-emotional disorders or trauma
can greatly influence one’s social communication. The impact of these
types of disorders on social communication are discussed in Section II
of this volume.

Socioeconomic Status
It has been well documented that children living in poverty are at
increased risk of poorer language outcomes in vocabulary and complex
syntax exposure and development (Dollaghan et al., 1999; Hart & Risley,
1995; Hoff, 2003; Huttenlocher, Vasilyeva, Cymerman, & Levine, 2002)
and tend to receive lower scores on standardized measures (Hart  &
Risley 1995; Heath, 1983; Qi, Kaiser, Milan, & Hancock, 2006; Qi, Kai-
ser, Milan, McLean, & Hancock, 2003). These children also have fewer
models of mainstream pragmatics and social communication styles and
126 • Hwa-Froelich

may learn neighborhood discourse styles and behaviors that may not be
understood or accepted in mainstream environments. In mainstream
environments, these pragmatic communication styles may be misin-
terpreted resulting in misunderstanding, possible conflict, and nega-
tive social outcomes, such as suspension or being expelled from school
(Delpit, 1995; Harry, 1992; Kalyanpur & Harry, 1999; Terrell & Terrell,
1996). Poorer linguistic outcomes and limited exposure to different
styles of social communication may negatively affect social communi-
cation development and ability as well as academic achievement. More
preschool students were referred for special education services based
on a particular subset of behaviors, violent physical reactions, impulsive
behaviors, and noncompliance (Nungesser & Watkins, 2005). Preschool
teachers reported that they perceived the home environment as the key
contributing factor for these behaviors, and few believed communica-
tion played a role in social competence. In fact, the Child Mental Health
Foundation and Agencies Network Project (2000) projected that chil-
dren with limited social skills may be placed in lower academic tracks,
which decreases the number of positive social interactions these chil-
dren may have with peers. Researchers have found that children living
in impoverished neighborhoods have been over-identified for special
education services (Donovan & Cross, 2002; Hosp & Reschly, 2004). In
these studies, demographic and economic factors predicted placement
of children into multiple categories of disability (mental retardation,
emotional disturbance, or learning disability). Demographic variables
included rate of ethnic groups, English proficiency, and number of fami-
lies with a person with a disability. Economic variables included hous-
ing value, family income, adult education level, and number of children
at risk. When academic achievement was paired with economic and
demographic factors, it also predicted the outcome of a disability cat-
egory (Hosp & Reschley, 2004). In other words, when children live in
environments where they receive less exposure to vocabulary and com-
plex syntax at home and have little opportunity to receive this kind of
linguistic exposure or discourse model in their neighborhoods, they
have lower academic achievement and are at increased risk of perform-
ing similarly as children with disabilities.

Hierarchy of Dependence
Culture is passed from one generation to the next through parenting
practices that teach social and communication behaviors to the children
(Vygotsky, 1934/1986; Wertsch, 1985). Cultural values are also commu-
nicated through the media, policies, laws, and the philosophies or ped-
agogy of institutions, such as schools (Vygotsky, 1934/1986; Wertsch,
 Social Communication Development • 127

1985). Cultural variations in communicative interactions appear to vary

across continua of dependence and power/distance in interpersonal
relationships (Hwa-Froelich & Vigil, 2004).
All cultures tend to value behaviors that are (a) more independ-
ent with other cultural members, (b) a mix of independent and inter-
dependent behaviors, or (c) more interdependent with other cultural
members (Greenfield & Cocking, 1994; Hofstede, 1984, 2001; Hofstede,
Pederson,  & Hofstede, 2002). Triandis (1995) termed these behaviors
as either individualistic or collective. Independent or individualistic
values support the idea that it is best to be separate and different from
others, whereas dependent or collective values support the view that it is
better to be dependent upon and similar to others. These cultural frame-
works affect parental goals and interaction behaviors when interacting
with their children. Children from diverse backgrounds may react to or
interpret mainstream social communication in different ways (Delpit,
1995).
The values of independence/interdependence influence parental
views of intentionality, language content, and use (Lustig  & Koester,
2009). More independent cultures, such as the US culture, view infants
as intentional at birth (Heath, 1983). In contrast, more interdependent
cultures, such as some Asian cultures, do not believe infants are inten-
tional until they can express real words. As a consequence, early vocali-
zations and cries were not attended to consistently (Heath, 1983; Westby,
2012). Linguistic content also varies among independent and depend-
ent cultures. For example, independent individuals tend to communi-
cate using more I and you pronouns with an emphasis on individuality,
independence, personal privacy, and needs (Kim & Choi, 1994; Lustig &
Koester, 2009; Lynch & Hanson, 2011). In contrast, the Latino culture
is more interdependent, and social competence is viewed as a priority.
Thus, Latino children may express polite social words prior to words
expressed for requesting or labeling (Sternberg, 2007; Westby, 2012).
Linguistic use can vary along this continuum from messages com-
municating an individual’s intention to messages seeking confirma-
tion, agreement, or invitation to participate. Because infants are viewed
as intentional in independent cultures, adults often label objects that
infants look at or hand the object to the infant to explore. Infants from
a more independent framework may develop requesting and labeling
early (Westby, 2012). Parents from dependent cultures may focus on
other communicative functions than labeling and requesting. In con-
trast, interdependent cultures may stress increased politeness toward
and inclusion of others. For example, Farver and Shinn (1997) found
that Korean children used more tag questions (“The children will stay in
128 • Hwa-Froelich

the castle, OK?”) than did US preschool children when playing with the
same stimuli. They hypothesized that the Korean children were demon-
strating more interdependent communication strategies showing more
concern and attention to their peers’ feelings and need to be included.

Interpersonal Relationships
Cultures also exhibit differences along the continuum of power and dis-
tance in social roles which influence communicative interactions (Green,
2002; Lynch & Hansen, 2011; Ochs & Schieffelin, 1986; Rogoff, 2003). In
cultures that view relationships along a continuum of increased power
and distance, persons are expected to know their place and role in dif-
ferent situations. In other words, persons viewed as having more power
expect and are treated by persons who have less power with more for-
mal communication and specific behavioral rules for interactions such
as addressing elders with differing degrees of formal address or special
treatment (Delgado-Gaitan, 1994; Greenfield, 1994; Ho, 1994; Nsame-
nang & Lamb, 1994; Scollon & Scollon, 1995; Suina & Smolkin, 1994;
Tapia Uribe, Levine, & Levine, 1994). To show more or less deference
to someone viewed as having more or less power, persons modify their
nonverbal and verbal communication (Hofstede, 2001; Triandis, 1995).
For example, to show more deference to an elder, some cultures use an
indirect eye gaze and address elders by Mr. or Mrs. Smith and use first
names for younger cultural members. In Chinese, jiĕjie is a special name
reserved for the oldest sister, whereas meimei is the name used for all
younger sisters, showing more respect for older than younger children.
Another example is shown by Vietnamese parents who socialize their
children to “talk sweet” as a way of showing respect to their elders and
teachers (Hwa-Froelich & Vigil, 2004; Hwa-Froelich & Westby, 2003).
In addition, gender roles may significantly differ from the mainstream
and gender communication styles may reflect these role differences
(Hwa-Froelich, 2004).
In cultures of less power/distance, individuals are viewed as hav-
ing equal power relationships. Communicative interactions display
equal power through direct, honest sharing of opinions, polite, indi-
rect directions, and more verbal than gestural or tactile communica-
tion. Directions are often framed as questions or suggestions to allow
for individual and independent choice rather than complete compli-
ance (Hwa-Froelich & Vigil, 2004). For example, in Western cultures it
is acceptable to address others by their first names regardless of age or
power differential. Special address is reserved for honorary members
such as the prime minister or the president or in special contexts such
as judicial proceedings.
 Social Communication Development • 129

In conclusion, factors of SES and culture must be considered in pro-

viding assessment and intervention services across the life span. SES was
a factor in the case example of Shelly. Her parents lacked the education
and knowledge they needed to interact and care for Shelly which placed
her at risk of failure to thrive. The early childhood special educator and
speech-language pathologist (SLP) helped Shelly’s parents reorganize their
belongings and increase lighting in the living room to allow Shelly to safely
explore her environment. They helped the parents learn how to share sto-
rybooks with Shelly by labeling pictures or talking about what they saw in
the pictures and asking questions to link the pictures to experiences they
had shared with Shelly. They helped the parents recognize and facilitate
collaborative talk about the pictures, taking conversational turns, and stay-
ing on the same topic for three to four turns. To improve Shelly’s prosody
and inflection, the early childhood teacher and SLP modeled exaggerated
inflection and slower prosodic patterns during conversational speech.
Over time, Shelly began to imitate these prosodic patterns until her conver-
sational speech began to sound more natural and less monotonous. With
the help of early intervention services, Shelly was able to learn and develop
functional communication and her parents learned how to contingently
respond to Shelly’s communication and provide age-appropriate language
stimulation and learning experiences. Cultural and social variations may
affect performance on assessments that could be misinterpreted especially
in the area of social communication. It is important that practitioners be
aware of families’ cultural expectations to appropriately address the com-
munication goals and needs of individual clients and prepare them for the
multiple communicative contexts in which they interact.

DISCUSSION QUESTIONS
1. What is the difference between primary and secondary inter-
subjectivity?
2. How does intersubjectivity support and facilitate social under-
standing development?
3. What kind of social interactions facilitate nonverbal communi-
cation development?
4. Describe the three stages of early pragmatic language develop-
ment.
5. What do children have to know to develop speech acts?
6. How do politeness rules affect social communication?
7. What are the maxims for cooperative conversational language?
8. Describe how poverty may influence one’s social communication.
130 • Hwa-Froelich

9. Describe how cultural differences in dependence and inde-

pendence may affect social communication.
10. Describe how cultural differences in interpersonal relation-
ships may influence social communication.

INSTRUCTIONAL RESOURCES
Joint attention across developmental disabilities. Retrieved from www.youtube.
com/watch?v=tif4U3OjT2M
Life’s First Feelings video. Retrieved from http://vimeo.com/44930499
Primary intersubjectivity Still face experiment. Retrieved from www.youtube.
com/watch?v=apzXGEbZht0

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 Section II
EVIDENCEBASED PRACTICE FOR
SOCIAL COMMUNICATION DISORDERS
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 6
ASSESSMENT AND INTERVENTION FOR
CHILDREN WITH PRAGMATIC
LANGUAGE IMPAIRMENT
Catherine Adams

A pragmatic impairment is a mismatch between language and context.

—Volden and Lord (1991)

LEARNING OBJECTIVES
Readers will
1. Become aware of incidence/prevalence statistics and the nature
of pragmatic language impairment.
2. Gain knowledge about the relationship between pragmatic
language impairment, social communication disorder, high-
functioning autism, Asperger Syndrome, and Specific Language
Impairment.
3. Be familiar with appropriate formal and informal assessment
procedures, particularly for pragmatics and high-level language
skills in pragmatic language impairment.
4. Gain information about evidence-based assessment and inter-
vention practices for children with pragmatic language impair-
ment.

141
142 • Adams

CASE STUDY
Lucas was aged 7 years, 11 months when he was assessed for participa-
tion in a speech-language intervention research project. Lucas had a his-
tory of language delay, unintelligibility, and comprehension difficulties
in the early years. Motor milestones and birth history was normal. There
was no history of speech and language difficulties in the extended family.
Lucas had passed all his hearing tests during the preschool period, and
there was no concern about his current hearing status. At age 3 years he
showed little inclination for imaginative or cooperative play with other
children. He attended a nursery school since the age of 3.5 years, where
there was some concern over his lack of engagement with staff and chil-
dren and his limited expressive language. Lucas is an only child; he lives
with his parents and has an extended family living nearby.
Lucas was referred for an initial speech-language assessment at the age
of 4 years 8 months. At that stage he could produce simple sentences but
his comprehension was significantly delayed. His receptive and expres-
sive vocabularies were limited for his age, and he was considered to have
a language disorder. He received a period of speech-language interven-
tion in the community pediatric clinic that focused on listening and at-
tention skills. As Lucas was about to enter mainstream education at age
5 years, a case conference was held to discuss management. The staff felt
that Lucas would not require attendance in a special education unit for
children with language impairment, but that he could continue to receive
speech-language therapy and additional support via a learning assistant in
the classroom. Lucas continues to receive this support to the present time.
At age 7, Lucas is intelligible and fluent, and to the lay observer, he
appears to have normal expressive language skills. However, his literacy
skills are developing slowly, and he is falling behind his peer group. Lu-
cas’s teacher has reported that he had literacy difficulties.
His parents’ main concerns are that he is making very slow progress
at school, and he gets confused when speaking to the extent that they
do not know what he is talking about. They report that it is difficult to
sustain a conversation with Lucas. They are aware it is not easy for peers
to engage with him and he appears increasingly socially isolated. Lucas
is very talkative and tends to dominate the topics of conversation, pre-
ferring to talk about familiar TV programs and computer games. He has
only one friend with whom he spends some time but mostly he prefers
to play on his computer at home.
The history and current reports of communication for Lucas suggest
that he has significant language and pragmatic difficulties that require
a full investigation. These difficulties are compounded by some social
interaction difficulties. Lucas’s lack of progress in language and literacy
 Children With PLI • 143

and his growing social difficulties indicate that he requires action to

prevent further problems in the school year and into adolescence. His
parents and education staff require specialist advice about the nature of
the underlying impairment and guidelines on how to support language
and pragmatic development.
Preliminary information about Lucas suggested that he has a Prag-
matic Language Impairment (PLI). This condition has recently also
been referred to as Social Communication Disorder (SCD). For the
purposes of clarity, the condition will be referred to as PLI, but the two
terms can be used interchangeably. The emergence of these categorical
and descriptive labels as well as issues of diagnosis are addressed in this
chapter.

CHARACTERISTICS OF PRAGMATIC LANGUAGE

IMPAIRMENT AND ITS RELATION TO OTHER CONDITIONS
Definitions and Labels
PLI is a type of developmental language impairment in which there is
disproportionate difficulty with pragmatics and social communication
compared to the structural aspects of language such as grammar and
vocabulary. Children with PLI show a range of pragmatic impairment
and language impairment features and may have a history of autistic
traits. As children who have PLI move into the later stages of language
development (at around age 4 years), the marked difficulty with prag-
matics and social communication becomes more apparent. Typically
these difficulties interfere significantly with social functioning and
acceptability. In addition, they may retain long-term developmental dif-
ficulties with language structure and discourse.
The term Pragmatic Language Impairment was first introduced
by Bishop (2000), who instigated the classic definition of a mismatch
between pragmatics and structural language abilities. Prior to 2000, this
condition was labeled semantic-pragmatic language disorder (Rapin &
Allen, 1987). PLI has always been a controversial term; it is not included
in the current Diagnostic and Statistical Manual of Mental Disorders
(5th ed.; DSM-5; American Psychiatric Association [APA], 2013),
and many autism researchers have firmly placed these children in the
broader autism phenotype, suggesting that the term PLI is redundant.
There is, however, evidence that children identified as having PLI do
not meet diagnostic criteria for autism (Bishop & Norbury, 2002; Ley-
fer, Tager-Flusberg, Dowd, Tomblin, & Folstein, 2008), and this led to
the retention by some of the term PLI. An ongoing debate exists regard-
ing the relationship between autism and Specific Language Impairment
144 • Adams

(SLI), specifically as to whether PLI represents an intermediate condition

(Bishop & Norbury, 2002), or represents a complex comorbid condition
in which autism and SLI coexist (Tager-Flusberg, Paul, & Lord, 2005).
Matters are complicated by the fact that symptomatology is overlapping.
The pragmatic deficits observed in PLI may be indistinguishable from
those of high-functioning autism (HFA). Common features of language
impairment, such as grammatical impairments and limitations in vocab-
ulary have been found in SLI and HFA, even when well-defined crite-
ria for diagnostic group inclusion are met (Kjelgaard & Tager-Flusberg,
2001; Leyfer et al., 2008).
The term PLI is likely to be replaced by Social Communication Dis-
order. The development of revised guidelines in the DSM-5 (APA, 2013)
has created a new category of Social Communication Disorder (SCD) in
the Neurodevelopmental Disorders/Language Impairment pathway. In
this formal diagnostic terminology, SCD is distinguished from Autism
Spectrum Disorder (ASD) and SLI.

DIAGNOSTIC CRITERIA FOR SCD IN DSM-5

In DSM-5, the following are given as diagnostic criteria for SCD:
• Persistent pragmatic difficulties which affect social function.
• Persistent language difficulties which may affect comprehen-
sion and expression.
• Absence of ASD (absence of restricted, repetitive patterns of
behaviour).
• Evidence from early childhood.
The adoption of a categorical diagnostic label (SCD) to replace PLI may be
welcomed in terms of referral for services. The label has an advantage in
that it implies, correctly, that the communication impairment has social
consequences. Research has shown, however, that there is a closer rela-
tionship with ASD than DSM-5 suggests and that there may be relatively
mild, but significant social issues which impact the child who has SCD
(Gibson, Adams, Lockton,  & Green, 2013; Whitehouse, Watt, Line,  &
Bishop, 2009) which could be overlooked in a non-autism diagnosis.

CURRENT INCIDENCE/PREVALENCE ESTIMATES

Although there is anecdotal information that speech-language patholo-
gists are being asked to provide services for more children who have
 Children With PLI • 145

pragmatic language impairments, precise incidence and prevalence esti-

mates are not available. There are two reasons for this: (a) PLI is not
widely recognized as a diagnostic category, and (b) recognition of the
condition is likely to be delayed until the child’s language profile can
show clear signs of pragmatic impairment, and this may not be until
after 4 years of age.
There are some relevant statistics, however, which shed some light on
the possible prevalence of PLI. Because PLI is a condition that is related
to both HFA and SLI, it is likely that the current populations of children
identified with these conditions contain a, relatively small, proportion
of children who have PLI. The incidence of SLI has been shown to be
around 7% (Tomblin et al., 1997), and about 60% of children identified
with SLI will go on to have language difficulties well into their elemen-
tary school years (Stothard, Snowling, Bishop, Chipchase,  & Kaplan,
1998). In a study of provision of special education in the UK for chil-
dren with persistent SLI, Botting and Conti-Ramsden (1999) found that
of this group, nearly a quarter could be described as having PLI. Autism
has a slightly lower prevalence than SLI (Yeargin-Allsopp et al., 2003).
It could be proposed that PLI might be most likely associated with the
autism spectrum condition, Pervasive Developmental Disorder (PDD),
because this represents a less severe form of autistic spectrum disorder.
The incidence of PDD has been estimated to be as high as 60/10,000
(0.6%) (Fombonne, 2003). PLI is therefore a significant but rarer type of
language disorder than is SLI.
General population studies provide another route to estimation of
the prevalence of pragmatic language difficulties, but at present there is
only one study which has a sufficiently well-constructed observational
measure and a contemporary approach to the diagnosis of PLI. This
is the work of Ketelaars, Cuperus, van Daal, Jansonius, and Verhoeven
(2010) in which parents from a community sample of 1,396 preschool
children (mean age 56 months) completed the Children’s Communi-
cation Checklist-2 (Bishop, 2003), an assessment of communication
from which a pragmatic composite score is computed (see the Assess-
ment section). Ketelaars et al., using a specific recommended cut off for
PLI, were able to identify 7.5% of the population as having significant
pragmatic difficulties in comparison to their overall communication
scores. Several of these children went on to have clinical diagnoses of
autism and language deficits. Using the same measures, Ketelaars et al.
found that 32.7% of children in an SLI group had identifiable pragmatic
impairments. However, it is not known if these would meet criteria for
PLI or were secondary to a broader communication disorder (see the
Definitions and Labels section).
146 • Adams

It is difficult to draw any precise conclusions about the prevalence or

incidence of PLI. Studies have drawn on different populations and with
different methods and measures. Definitions of PLI are not sufficiently
well developed and validated to allow precise identification of the condi-
tion, and it is likely that all of the studies so far are describing children
with a range of diagnosed conditions who also have pragmatic difficul-
ties. Definitive information will have to wait for better delineations of
the nature of pragmatic difficulties.

THE NATURE OF PRAGMATIC LANGUAGE IMPAIRMENT

The nature of the communication disorder in children with PLI has
three main components: pragmatic deficits, structural language deficits
and social interaction deficits. Although children will show some defi-
cits in all three components, they may vary independently in severity so
that individual communication profiles may diverge within the group.
Children with PLI rarely demonstrate all of the behaviors listed in the
following, and heterogeneity should be anticipated.

Pragmatic Deficits
Pragmatics is a domain of linguistics that defines how language form
is adapted and used to convey meaning in social situations. Pragmatic
behaviors are typically exhibited in social situations and in discourse
at above-sentence level, for example in conversations, in casual verbal
exchanges between interlocutors and in accounts of events or narra-
tives. Children who have PLI may present difficulty with all these verbal
exchanges, and the normal smooth flow of conversation/interactions is
disrupted.
The main pragmatic characteristics of children with PLI are set out
below and based on accounts from Bishop and Adams (1989) and
Adams (2001, 2013):
• Turn-taking difficulties: The child is unable to judge when
turn-taking signals are being provided by the interlocutor and/
or is unable to provide those signals, and consequently, there is
over-talking (verbal overlaps and clashes) in the interaction.
• Lack of responsivity to interlocutor: The child does not respond
to a verbal invitation or direct question, and the typical sequence
of exchange of speech acts is disrupted.
• Poor coherence/cohesion of events in discourse: The child
provides accounts of events or descriptions that are difficult to
 Children With PLI • 147

understand as ideas are illogically sequenced or not adequately

related to each other.
• Tendency to dominate discourse or conversation: The child
talks more often than would be expected in a social situation.
This is more than chattiness; there is a compulsion to talk.
• Misjudging required information: The child provides too much
information for the interlocutor (related to conversational
dominance), and the important information is lost in the detail.
He or she will appear pedantic to the observer. The child may
also provide too little information, so that the interlocutor is not
sure what is being talked about.
• Topic management problems: The child does not follow the
expected conventions which govern the way in which topic
(what is being talked about) is handled in conversation/dis-
course. Children with PLI may show sudden topic shifts or drift
into an unrelated topic.
• Initiations of exchanges: The child with PLI may initiate con-
versational exchanges more frequently than expected by mak-
ing many unsolicited statements or by asking many questions.
However, some children with PLI can do just the opposite—they
appear to be relatively passive and make very few initiations.
• Paralinguistic behaviors such as abnormalities of intona-
tion similar to those seen in HFA (Peppé, McCann, Gibbon,
O’Hare, & Rutherford, 2006), and stereotyped language/learned
phrases (Bishop & Adams, 1989) may also be present and have
significant impact on overall pragmatic profiles.

Structural Language Deficits

Children who have PLI and who have passed the preschool years dem-
onstrate a range of difficulties in acquiring language forms. Again this
is highly variable, with some children having significant and severe lan-
guage impairment and others presenting as relatively verbally fluent and
able. The range of language impairment characteristics in PLI is as fol-
lows:
• Difficulties with sentence grammar and lexical semantics: Chil-
dren with PLI frequently show persistent minor errors of syntax
(Bishop & Adams, 1989). However, structural language impair-
ments are variable throughout this group (Adams et al., 2012) and
that where they do occur they tend to be less marked than those
found in typical SLI (Freed, Adams,  & Lockton, 2011). Word
finding and semantic difficulties (Adams, 2001), particularly
148 • Adams

with abstract words (Botting  & Adams, 2005) have also been
reported (Ketelaars, Hermans, Cuperus, Jansonius,  & Verhoe-
ven, 2011).
• Discourse comprehension problems: For a child with these
issues, he or she is unable to follow the complex language forms
appearing in real time. From a pragmatic perspective, the child
who does not understand often dissembles or makes up an
unrelated response (McTear, 1985), which can appear pragmati-
cally odd.
• Difficulty interpreting non-literal language: In a highly idi-
omatic language such as English, the child with PLI may have
difficulty in understanding language forms such as idioms,
metaphors, jokes and sarcasm. Children with SLI also have
problems with these forms (Vance & Wells, 1994) and there is
no evidence that children with PLI are disproportionately poor
at interpreting this sort of language processing.
• Difficulty in making inferences: The child with PLI typically
shows limited ability to make appropriate inferences, particu-
larly in naturalistic discourse, and may therefore misinter-
pret meanings. There is mixed evidence of disproportionate
impairment of inferential comprehension in children with PLI
(Adams, Clarke, & Haynes, 2009; Norbury & Bishop, 2002).
• Misinterpretation of meanings in context: Children with PLI or
SLI have difficulty in disambiguating homonyms and may not
be able to identify the correct meaning of the word. Accounts
of homonym misinterpretation (Bishop, 2000), as for inference
comprehension, in PLI are largely anecdotal and there is no evi-
dence of a specific deficit in PLI compared to SLI (Norbury, 2005).
• Narrative disorganization: The child shows disorganized nar-
ratives (stories, accounts of recent events) resulting in unintel-
ligible discourse and listener confusion (Adams, 2001).

Social Interaction Deficits

Bishop (2000) refers to the social interaction deficits in children with
PLI as being mild in nature and insufficient to indicate autism spectrum
disorder and this is reflected in clinical descriptive accounts in the lit-
erature (Adams, 2001). Group studies of children with PLI have indi-
cated poor peer social interaction ratings (Botting & Conti-Ramsden,
1999) and limitations of social cognition compared to children with
SLI (Shields, Varley, Broks, & Simpson, 1996). Empirical observational
research by Gibson et al. (2013) has shown that a well-defined group of
children with PLI displayed some difficulties with social interaction (as
 Children With PLI • 149

observed on the school playground) but that these were less severe than
children with HFA. Broader social communication features in children
with PLI such as limited use of gesture to supplement communication
and gaze aversion suggestive of ASD traits have been reported (Bishop,
Chan, Adams, Hartley, & Weir, 2000). Children with PLI therefore are
typically at risk of mild social interaction and social relationship dif-
ficulties. It is likely that this will be reflected in limited friendships and
consequently restricted opportunities to develop social interaction skills
in the typical contexts of childhood.

Associated Developmental Difficulties in PLI

Behavioral difficulty is a common correlate of language impairment.
Research has shown that in children with SLI, pragmatic abilities are
associated with behavioral and emotional difficulties in development
(St. Clair, Pickles, Durkin, & Conti-Ramsden, 2011). There is increasing
evidence of a link between social communication difficulties in early
life and later behavioral difficulties (Donno, Parker, Gilmour, & Skuse,
2010; St.  Pourcain et  al., 2011; see Chapter  11). Ketelaars, Cuperus,
Jansonius, and Verhoeven (2010) found that behavioral problems are
closely associated with pragmatic competence in a community sam-
ple. The same research showed that children with PLI frequently show
externalizing behavioral problems, particularly hyperactivity and lim-
ited prosocial behaviors. A qualitative study Baxendale, Lockton, Gaile,
and Adams (2013) provided accounts of family difficulties and problems
in friendships for children with PLI. This is an area where more research
is required since the implications for social integration and well-being
as well as intervention are significant.
Children with PLI are likely to show additional learning needs often
associated with children with SLI, including difficulties with reading
comprehension and accuracy (Freed et al., 2011). Long-term outcomes
for individuals who have PLI reveal a specific difficulty in forming
adult relationships in later life (similar to that in ASD) and some per-
sistent difficulties with social use of language. However, adults with
a PLI history have relatively normal literacy and structural language
skills, fewer autism symptoms than comparable ASD individuals, and
better work skills outcomes than adults with a history of SLI (White-
house et al., 2009).

REFERRAL PRACTICES AND ASSESSMENT METHODS

Although there are no retrospective studies of early language history,
clinical accounts suggest that children with PLI show late emergence of
150 • Adams

language, including receptive language delay (sometimes severe) and an

early history of mild autistic features (such as echolalia) with impaired
social relationships (Adams, 2001). Since the full profile of PLI tends to
emerge as grammatical and vocabulary development progresses, recog-
nition of the condition may not happen until after age 4.
Referral should be made to a speech-language pathologist for expert
assessment of communication skills. Referral to a child medical prac-
titioner (pediatrician) for an overall developmental assessment and/or
child psychiatrist for assessment of autism characteristics and diagnosis/
exclusion of autism spectrum disorder should also be made. Because
children with PLI often have additional learning needs with literacy,
careful monitoring of reading, writing, spelling, and numeracy must be
ensured within the education system.

Principles of Assessment
Assessment of the communication of the child with PLI is an expert and
specialist undertaking. Speech-language practitioners’ evaluation of the
communication features of pragmatic language impairment should be
based on six key principles:
• Assessment should be comprehensive enough to adequately
evaluate language skills, pragmatic ability, and social interac-
tion during communication.
• Evaluation must be individualized, because PLI is variable in
presentation; this will allow scrutiny of characteristics of the
individual which may be targeted in intervention.
• Evaluation should be carried out as part of multidisciplinary
teamwork to ensure that appropriate ASD diagnostic practice
and expert language assessment information are available for
overall identification of strengths and needs.
• A mixture of contexts should be used during assessment. The
context of assessment is crucial; children with PLI tend to do
better with structured contexts so a mixture of formal, infor-
mal and naturalistic contexts is essential. Expert assessment
should be extended to non-clinical contexts (home, classroom,
and playground) to obtain a representative profile of social
interactions.
• Carers’ and teachers’ accounts of communication and social
functioning should be actively elicited. The people who live and
work with the child on an everyday basis will be the source of
key information that will not be accessible in clinical evaluation.
Evaluation should include interviews with carers and teachers
 Children With PLI • 151

to gain additional information about the impact of communica-

tion deficit on daily life and peer relationships.

Language Assessment
The speech-language practitioner should use standardized tests to iden-
tify the language competency of children with PLI. Although many tests
are available, an indicative list of tests suitable for this purpose is:
• Clinical Evaluation of Language Fundamentals (CELF-4; Semel,
Wiig, & Secord, 2006a): includes subtests of Concepts and Fol-
lowing Directions, Formulated sentences, Understanding para-
graphs, and Word classes.
• Test of Word Finding (German, 2000) and Test of Word Knowl-
edge (Wiig  & Secord, 1992): subtests include definitions,
multiple-meaning words (homonyms), figurative language and
receptive and expressive vocabulary.
• Test of Language Competence (Wiig & Secord, 1989): subtests
include Making Inferences, Re-creating Speech Acts and Figu-
rative Language.
• Expressive Receptive Recall of Narrative Instrument (ERRNI;
Bishop, 2004): a test that requires the child to tell a story from
a set of pictures, to recall the story content without the pictures
and to answer questions designed to tap into overall inferential
comprehension.
• Assessment of Comprehension and Expression (ACE; Adams,
Cooke, Crutchley, Hesketh, & Reeves, 2001): contains subtests
of Narrative, Non-Literal Comprehension and Inferential Com-
prehension.
The speech-language practitioner may supplement formal testing of
language with informal procedures such as observation of narrative
constriction and understanding of inference in stories. Many tasks fall
within this category, and these are likely to vary according to local prac-
tice and experience. Two tasks which have been used in research with
children who have PLI are (a) the Strong Narrative Assessment Proce-
dure (SNAP; Strong, 1998): this elicits narratives using picture materi-
als and provides a method of analysis of narratives; and (b) the Happé
Strange Stories (Happé, 1994): a series of short stories which aim to tap
into comprehension of and explanations for use of non-literal forms of
language including jokes and sarcasm. O’Hare, Bremner, Happé and
Pettigrew (2009) published norms and means for 5- to 12-year-olds for
short version of the Happé Strange Stories task. However, Young, Diehl,
152 • Adams

Morris, Hyman, and Bennetto (2005) found that SNAP did not identify
any unique characteristics of narrative in children with PLI.

Pragmatics Assessment
Preschool assessments may include parent/carer report of communi-
cation skills or direct observation. In Wetherby and Prizant’s (2002)
Communication and Symbolic Behavior Scales–Developmental Profile
(CSBS-DP), observation of pragmatics were carried out from record-
ings using a simple checklist of communicative behaviors, including use
of voice to communicate, affective signaling and communicative ges-
tures. The Clinical Evaluation of Language Fundamentals–Preschool,
second edition (Semel, Wiig, & Secord, 2006b), contains a Pragmatics
Profile section which enables the practitioner to describe language use;
however, this is not standardized. The Language Use Inventory (LUI;
O’Neill, 2007) is a checklist, completed by parents/carers, recording
the child’s uses of language and gesture to communicate intention. It
also includes items related to understanding of others’ knowledge. The
LUI is not standardized but has good internal consistency and dis-
criminant validity and therefore stands out in the preschool field as a
well-developed and evaluated scale. Other informal methods such as
the Peanut Butter Protocol (Carpenter  & Strong, 1988; Creaghead,
1984) provide a means of eliciting communicative intent. In this task
the child is tempted to use a sequence of communicative intents by the
provision of given situation prompts, such as a jar of cookies that is dif-
ficult to open. Similar elicitation and suggestions for informal tasks are
provided by Roth and Spekman (1984). A more comprehensive review
of pragmatic assessment for early language learners is provided by Paul
and Norbury (2012).
Preschool assessment methods are unlikely to evaluate the more com-
plex pragmatic features of PLI reported above. Adams and Lloyd (2005),
for example, used a modified version of the Peanut Butter Protocol with
a group of elementary school-age children with PLI but found that they
could complete this task easily; that is they were able to demonstrate the
full range of communicative intents elicited via this procedure and did
not differ from typically developing children.
Pragmatic assessments for school-age children are available in the
form of pragmatic behavior checklists, teacher and parent/carer report
forms and standardized tests. The earliest observational checklist was
the Pragmatic Protocol (Prutting  & Kirchner, 1987) which is suitable
for children 4 years and older who have substantive expressive language
skills. The protocol allows the practitioner to profile aspects of lan-
guage and communication (including pragmatics) as appropriately or
 Children With PLI • 153

inappropriately used. Examples of communicative acts included in the

protocol are Utterance acts (e.g., intelligibility and prosody), Propo-
sitional acts (e.g., specificity and accuracy of lexical selection), illocu-
tionary and perlocutionary acts (e.g., speech act pair analysis, topic
introduction and maintenance) and turn taking. The Pragmatic Protocol
has considerable merit as a checklist but it has not been validated and it
contains ratings of non-pragmatic variables such as prosody. The CELF-4
(Semel et al., 2006a) also contains a Pragmatic Profile appropriate for
older children. This is a criterion-referenced assessment consisting of a
checklist of pragmatic features to be completed by the speech-language
practitioner, the teacher or a parent/carer. Scores are allocated on fre-
quency of occurrence of listed pragmatic behaviors, and totaled scores
provide an indication of performance compared to children who have
typical language development. This is one of the few assessments to offer
some norm-comparative information. Other pragmatic checklists are
available that can function as observational guides, but these have not
been validated and their reliability is currently unknown.
In language testing, context and mode of delivery are typically strictly
controlled. The nature of pragmatics as a set of rich descriptions of the
use of language in naturalistic contexts does not lend itself well to this
controlled paradigm. Consequently, formal tests of pragmatics are rare.
Some aspects of pragmatics and supporting language skills are addressed
in the Test of Pragmatic Language–2 (Phelps-Teraski & Phelps-Gunn,
2007). This assessment contains a comprehensive set of picture stim-
uli accompanied by short texts/stories to which the child is asked to
respond. Items are designed to tap into various aspects of pragmatic and
emotional/social understanding. This test has the advantage of having a
set of standardized norms from 6 years 0 months to 18 years 11 months.
Its potential to identify pragmatic language impairment is compromised
by its heavy reliance on complex language input, and it has been shown
to be less reliable than other standardized instruments (e.g., CCC-2; see
the following discussion) at identifying pragmatic language impairment
(Volden & Philips, 2010). The Social Language Development Test: Ele-
mentary (Bowers, Huisingh, & LoGiudice, 2008) has similar elements
to the Test of Pragmatic Language, but uses a method in which chil-
dren’s responses to portrayed peer interactions are elicited. Aspects of
pragmatics which are included are multiple interpretations of social epi-
sodes, negotiation with peers and inference of emotions in context. The
Social Language Development Test is aimed at 6- to 11-year-olds and
has satisfactory test–retest reliability and good internal consistency.
There have been a number of attempts to develop a clinically relevant
and manageable observation scale for pragmatics or social communication
154 • Adams

in childhood. The most recent of these is the Social Communication

Coding System (Olswang, Coggins, & Svensson, 2007) that codes social
communication behaviors (such as passivity, prosocial behavior) in a
classroom setting. Whereas this is not a pure pragmatics assessment, it
enables the practitioner to take into account the broader social interac-
tion abilities of children with PLI. The scale has also been subjected to
satisfactory validity and reliability testing (Olswang, Svensson, Coggins,
Beilinson, & Donaldson, 2006) and has good concurrent validity with
parent/teacher report (Olswang, Svennson, & Astley, 2010).

Evaluation and Differential Diagnosis of PLI

The current best practice in identifying the presence of PLI can be
obtained using the Children’s Communication Checklist–2 (CCC-2;
Bishop, 2003). On the CCC-2, a parent, a carer or a familiar adult rates
the frequency of occurrence of a range of structural language, pragmatic
and autistic-like communication behaviors in the child. Two summary
scores are then derived: a General Communication Composite that
indicates the presence of communication impairment and a Social
Interaction Deviance Composite that can indicate the presence of a
disproportionate pragmatic impairment. The CCC-2 is well validated
although there are some accepted limitations on its diagnostic accuracy
(Norbury, Nash, Baird, & Bishop, 2004) and some risk of inconsistent
parent reports (Geurts & Embrechts, 2008). In further research, Geurts
and Embrechts (2010) studied the convergent validity of the CCC-2 and
the Nijmegen Pragmatics Test, a direct observational measure in chil-
dren with language impairment and typical development. Some con-
vergence of scores/observations between the two tests was found, but
there is still a need for caution in using a single measure to identify the
presence of PLI.
Diagnostic criteria that distinguish children with PLI from other
conditions are as follows (note that these require further validation
research). PLI is differentiated from SLI by consideration of dispro-
portionality of the impairment of pragmatics compared to the impair-
ment in structural aspects of language such as grammar, vocabulary,
and phonology. The Social Interaction Deviance Composite (SIDC)
score of the CCC-2 can indicate the likely presence of PLI, but should
not be used in isolation, as there is no precise cut-off between SLI and
PLI. Children with severe receptive language impairments, for example,
can present odd pragmatic behaviors (likely to be reported as frequent
behaviors by parents on CCC-2) that are compensatory strategies to
remain engaged in interaction. It is necessary therefore, to inspect carefully
 Children With PLI • 155

high-rated items on CCC-2’s Pragmatic Composite scale. The best

diagnostic practice is to combine use of the CCC-2 SIDC with high-level
language assessment findings and specialist speech-language practi-
tioner opinion.
Intellectual impairment is distinguished from PLI using a non-verbal
IQ cut-off. Individuals who have a PLI have non-verbal IQ scores greater
than 70; individuals with an intellectual impairment have non-verbal IQ
scores that are less than 70. This is identical to the IQ cut-off used for
SLI diagnosis. Narrower definitions of SLI use a nonverbal score cut-
off that is greater than 85. In clinical practice, children with PLI with
a non-verbal IQ in the range of 70 to 85 are likely to present with a
similar profile of language impairment as children with PLI who have
non-verbal IQ greater than 85.
It has been proposed that SCD/PLI can be differentiated in diagnosis
from ASD, because SCD/PLI do not demonstrate the repetitive behav-
iors and restricted interests dimension of ASD. However, this evaluation
is usually outside the scope of practice of the speech-language practi-
tioner. Diagnosis of autism spectrum disorder should be carried out by
a qualified practitioner (pediatrician/psychiatrist). Information about
language impairment status would not invalidate a diagnosis of ASD –
the two co-occur frequently. However, the absence of an ASD diagno-
sis in the presence of a significant impairment in pragmatics would be
indicative of SCD according to the DSM-5.

CASE HISTORY: ASSESSMENT

Lucas was referred to the intervention research project by his local
speech-language pathologist. She described him as having trouble un-
derstanding and interpreting social contexts and non-verbal communi-
cation and as having a significant pragmatic difficulty and some difficulty
with non-literal language. A summary of formal assessment findings is
shown in Table 6.1.
Lucas’s conversational skills were then assessed using an experimen-
tal checklist of pragmatic features (Targeted Observation of Pragmatics
in Children’s Conversation [TOPICC]; Adams, Lockton, Gaile, & Freed,
2011). On this assessment he was observed to have difficulty with man-
agement of topic, responsiveness to the interlocutor and with making
accurate judgements of listener knowledge (for the purpose of outcome
interpretation, his score on TOPICC was overall severity score = 17.
Lower scores indicate improvement). Lucas’s parents completed the
156 • Adams

Table 6.1 Assessment Summary for Lucas at the Pre-Intervention Stage

Test Findings

CELF-4 (UK version) Core language standard score = 66

Expressive language standard score = 69
Receptive language standard score = 61
Expressive Receptive Recall of Narra- Story comprehension = 2nd centile
tive Instrument (Bishop, 2004) Initial story telling = 1st centile
British Picture Vocabulary Test Receptive vocabulary = 22nd centile
(Dunn, Dunn, & Whetton, 1997)
Children’s Test of Non-Word Repeti- Below the 10th centile
tion (Gathercole & Baddeley, 1996)
Children’s Communication General Communication composite = 28
Checklist-2 (parent report; (indicates communication impairment)
Bishop, 2003) Social Interaction Deviance Composite = 5
(indicative of disproportionate pragmatic
impairment)

Social Communication Questionnaire (Rutter, Bailey,  & Lord, 2003).

The total score on this assessment indicated that Lucas may fall into
the Pervasive Developmental Disorder category, but this would need
to be confirmed with more detailed investigation of social functioning.
In addition, opinions and observations regarding Lucas’s current social
communication, social interaction ability, peer relations, and language
ability were solicited from his parents and his class teacher.

EVIDENCEBASED INTERVENTION PRACTICES

FOR SOCIAL COMMUNICATION PROBLEMS
ACROSS THE LIFE SPAN
The standard Cochrane systematic review of language and communica-
tion disorders treatments (Law, Garrett,  & Nye, 2003, 2010) contains
no eligible studies of pragmatic interventions. Gerber, Brice, Capone,
Fujiki and Timler (2012), in a further systematic review, examined
the quantity and levels of available evidence for the effects of conver-
sational and/or pragmatics treatments for children with pragmatic
language difficulties. The review found insufficient quantity or type of
evidence available to carry out a meta-analysis. Most studies found were
small-scale or exploratory and the stated contents of intervention or
goals varied across studies, making even narrative comparison difficult.
 Children With PLI • 157

The only randomized controlled trial for older children with PLI is that
of Adams et al. (2012) which was published after Gerber et al.’s review.
There are no published clinical guidelines based on empirical research.
At a lower level of evidence, single case studies and case series have uni-
versally indicated that children with PLI can make progress in social
communication and language skills, given the right support (Adams,
Lloyd, Aldred, & Baxendale, 2006; Merrison & Merrison, 2005; Timler,
Olswang, & Coggins, 2005a).
Choice of social communication intervention will depend on the age
and communication status of the child. Consideration is first given to
intervention models in the preschool period.

Preschool Intervention Approaches

Preschool speech-language treatments are likely to be aimed at encourag-
ing use of language and establishing skills that underpin social interac-
tion and language comprehension. This would typically take the form
of advice and training of parents and carers. The intervention model of
choice is likely to be the developmental–social model, in which facilita-
tion of social interaction via verbal and non-verbal means is encouraged
through a child-centred approach. This model has many variants and has
been widely reported; for example versions of the developmental-social
model are the Hanen method (Manolson, 1992), responsive interaction
(Kaiser, Hancock, & Hester, 1998), and the child-oriented approach advo-
cated by Fey (1986). The central tenet of the developmental–social model
and all its variants is the facilitation of social interaction and appropriate
communicative intents. A review of relevant methods and their effective-
ness can be found in Roberts and Kaiser (2011). Specific examples of early
developmental–social interventions are reported in robust clinical trials.
Because PLI is not typically diagnosed in the early preschool years,
evidence of intervention effects are best extrapolated from trials of
toddlers with ASD. Two robust clinical trials of developmental–social
interventions for toddlers with autism have demonstrated evidence
of positive treatment effects on parental communication synchrony
(Green  et  al., 2010) and joint engagement (Kasari, Gulsrud, Wong,
Kwon, & Locke, 2010). Further consideration of these interventions is
provided in Fannin and Watson’s chapter in this volume.

Elementary School-Age Interventions

The two principle models supporting direct individual intervention dur-
ing the school years are those of Brinton and Fujiki (1995) and Adams
(2005, 2008). Brinton and Fujiki’s social communication intervention
158 • Adams

focuses on the facilitation of conversational interaction with children

with a range of language impairments, including SLI. Pragmatic compe-
tence is viewed as part of an integrated model in which language expres-
sion and comprehension skills contribute to social communication and
to social interaction which, in turn, contribute to peer interactions,
friendships, and social well-being (Brinton, Fujiki, & Robinson, 2005).
The overall aims in this model are primarily ones of social integration
and self-esteem, mediated through specific language-based pragmatic
targets, such as taking turns in a conversation (Fujiki, 2009). Brinton,
Robinson, and Fujiki (2004) described an intensive conversational pro-
gram, entitled The Conversation Game, for children who have language
impairments. Further information on these approaches can be found in
Chapter 8 in this volume.
Adams’s Social Communication Intervention Programme (SCIP) is
based on a model of social communication in which competencies in
social interaction/understanding and language ability interact during
early development. From this process emerges pragmatic competence.
That is pragmatics is viewed as an emergent phenomenon in a dynamic
system (Karmiloff-Smith, 1998) rather than an isolated linguistic skill.
The SCIP model of intervention therefore contains therapy goals in
three main components:
• language processing (receptive and expressive high-level lan-
guage);
• pragmatics and metapragmatics;
• language-mediated social understanding and social interpreta-
tion.
The SCIP therapy resource (Adams  & Gaile, 2014) is organized into
these key components of intervention, each containing a large number
of therapy goals and activities (e.g., basic narrative skills, topic man-
agement, interpreting social context cues). SCIP Intervention was
developed for children aged between 6 and 11  years of age. It can be
adapted to provide appropriate materials for a wide range of children’s
social communication and language needs and for children who have
high-functioning ASD or for older children with language impairments.
SCIP Intervention adheres to the same principles of integration of lan-
guage and social communication goals as Brinton’s and Fujiki’s. It pro-
vides a phased method of intervention. In Phase 1 children are prepared
for social communication practice via work on underpinning commu-
nication skills, such as comprehension monitoring and metapragmatic
knowledge. In Phase 2, individual social communication, pragmatic,
 Children With PLI • 159

and language needs are mapped to individual needs and the child par-
ticipates in therapeutic activities with the practitioner and co-workers/
parents. In the final stage of SCIP Intervention, each child participates
with carers, buddies and teaching staff in a set of personalized ther-
apy activities that extend work done in Phase 2 beyond the treatment
context. Both Adams’s (2008) and Fujiki and Brinton’s (1995) models
underline the importance of the level of language input, the use of ‘meta’
language in therapy and the essential use of functional contexts to sup-
port social learning. SCIP Intervention uses a series of intervention prin-
ciples, which underpin all management decisions (shown in Table 6.2).
The effectiveness of SCIP intervention was examined in a rand-
omized controlled trial (Adams et  al., 2012). Eighty-six children with
PLI (aged between 6 and 11  years) were allocated randomly to SCIP
versus Treatment as Usual groups. Children in the intervention group
received 20 individual therapy sessions in school from a specialist
research speech and language therapist or a closely supervised therapy
assistant. Evidence in favour of the intervention was found in meas-
ures of parent-/carer-rated pragmatic competence, blind-rated change
in conversational skills, parent/carer opinion of post-treatment change
in social communication and language skills and teacher opinions of
post-treatment change in classroom learning skills.

Table 6.2 Principles of Intervention in SCIP Intervention

Principle Description
Adaptation Develop, adopt, and practice communi-
cation strategies which are less disrup-
tive to social interaction
Language support Strengthen some aspects of language
processing by structured practice and
building confidence and fluency in
language tasks
Environment modification Modify the language environment to
support interpretation of language in
social interactions
Metapragmatic learning Facilitate pragmatic conventions using
metacognitive methods appropriate for
school-age children
Generalization to socially meaningful Incorporate individual social needs/
contexts situations into language and pragmatic
therapy
160 • Adams

Evidence from other researchers exists primarily at the level of single

case-studies. Timler, Olswang, and Coggins (2005a) evaluated a social
communication intervention in which a child was supported to appraise
social communication situations from various perspectives, including
those of peers. Stages of the intervention are presented but this approach
has not been trialled to date with a clinical population.
Social Skills Training (SST) refers to a set of approaches that aim
to teach specific social behaviors as a means of enhancing interaction.
Social skills training programs typically consist of a series of programed
activities that are often carried out in a group context (Segrin & Givertz,
2003) and are founded on learning and behavioristic treatment princi-
ples. SSTs have the advantage of being relatively simple to implement
and not requiring specialist knowledge. The disadvantage of SST in
relation to PLI is that there is no specific support for language process-
ing in the form of language scaffolding. Although there is some evi-
dence of social skills gains in some populations because of SST (Matson,
Matson,  & Rivet, 2007; Reichow  & Volkmar, 2010) evidence of gen-
eralization of learned skills is weak. The meta-analysis by Koenig, De
Los Reyes, Cicchetti, Scahill, and Klin (2009) of SST evidence concluded
that methodological limitations and problems of generalization existed
in most SST effectiveness studies.

Classroom, Group, and Peer Interventions

Evidence of intervention effects for classroom treatments exist at the
level of the single case study only. Timler, Olswang and Coggins (2005b)
devised a social communication intervention which incorporated class-
room peers into social communication therapy for a child with social
communication difficulties. Peers were found to facilitate communica-
tion targets and support generalization. Timler and Vogler-Elias (2007)
presented a single case study of a child with social communication
needs in which a range of people in the child’s school, including the
clinician, the teacher and peers, mediated the communication training.
This study also provides practical guidelines on classroom-based inter-
vention. Expert opinion (Adams & Gaile, 2014) recommends the use of
buddies or peers in SCIP intervention, both for reasons of generaliza-
tion and to provide age- and culture-appropriate models of talk.
Parent Programs
There are no programs of intervention for older children with PLI that
are specifically written for parents. Both Fujiki (2009) and Adams and
Gaile (2014) stress the important role of the parent or carer in both
planning and carrying out social communication intervention. The
parent or carer’s role in mediating everyday social communication
 Children With PLI • 161

situations which are problematic, place him or her in an ideal position

to monitor the implementation of strategies learned in therapy and to
reflect on progress made. Baxendale et al. (2013) found that parents/car-
ers involved in the SCIP trial valued being provided with information
about ongoing therapy and used this information to adopt communica-
tion strategies at home.
Overall, evidence relating to intervention for children who have PLI
is indicative of positive effects. Case series and prospective case stud-
ies of conversational treatments have suggested potential efficacy of
speech-language treatments. A single robust trial of a specialist pragmatic/
language intervention has suggested positive outcomes for social com-
munication. There remain many questions still remaining regarding
individuals’ response to intervention and issues of intensity and who
can best deliver therapy.

CASE STUDY: TREATMENT AND OUTCOMES

At the end of assessment, Lucas entered the treatment arm of the Social
Communication Intervention Project (Adams et al., 2012). During the
intervention process, Lucas took part in 20 face-to face individual inter-
vention sessions with the speech-language practitioner. Lucas’s parents
attended some treatment sessions, and his support assistant attended
more than half of the sessions. A buddy from Lucas’s class joined in later
sessions in order to provide relevant social context and models in the
intervention. Intervention components in Lucas’s Phase 2 SCIP Inter-
vention (Individualized phase) are shown in Table 6.3.

Table 6.3 Content of the Individualized Phase of SCIP Intervention for Lucas

Components of SCIP Intervention
Language Processing Pragmatics Social Understanding/
Social Interpretation
Vocabulary and Word Conversation and Understanding social con-
Knowledge metapragmatic skills text cues in interactions
(including requests for
clarification)
Improving Narrative Understanding informa- Understanding emotion
Construction tion requirements cues in interactions
Enhanced Comprehen- Understanding and man- Understanding thoughts
sion Monitoring aging topic in conversation and intentions of others
162 • Adams

Lucas was reassessed 6 months after the end of intervention, using

raters blind to intervention versus control group status when possible.
His parents and teacher reported that, whereas he still had significant
communication problems, they had seen great improvement in listen-
ing, narrative, confidence in communication skills, and in conversa-
tion abilities: “We can actually have a conversation with him at the end
of the school day now.” Lucas’s teacher reported noticing a significant
change in his participation in classroom discussions and in attention
paid to group instructions. Conversational ability was reassessed by
an independent researcher blind to the fact that Lucas had received
intervention. TOPICC overall score had decreased from 17 to 12 with
significant improvements observed in responsiveness and decreased
conversational dominance. Narrative ability (ERRNI) had improved
slightly, but his Clinical Evaluation of Language Fundamentals–Revised
(CELF-R; Semel, Wiig, & Secord, 1989) scores remained static. Lucas
remained a child with a severe, persistent communication problem, but
there had been significant gains according to those who know him best.

DISCUSSION QUESTIONS
1. What might be the relationship between pragmatic language
impairment and high-functioning autism?
2. Does the category of Social Communication Disorder in DSM-5
clarify the diagnostic issues described in this chapter?
3. What principle features do pragmatic language impairment and
specific language impairment have in common, and why might
this discussion be crucial to intervention planning?
4. What are the broader social consequences of pragmatic lan-
guage impairment for the child and his family?
5. Describe a package of assessment for a 10-year-old child sus-
pected of having pragmatic language impairment.
6. Describe an intervention program for the same child, showing
how the current evidence base supports the choices made.
7. How could practitioners balance the need for individualized
treatment for children who have pragmatic language impair-
ment when resources are finite?
8. Describe some ways in which communication intervention can
be personalized for the child with pragmatic language impair-
ment.
9. Which measures of conversation, pragmatics, and language could
be employed as appropriate outcome measures at the single case
level?
 Children With PLI • 163

CLINICAL RESOURCES
Description of Conditions
Social Language Use and Pragmatics (ASHA): www.asha.org/public/speech/
development/pragmatics.htm
What Is Pragmatic Language Impairment?: www.slideshare.net/RALLICampaign/
what-is-pli
www.asha.org/slp/PragLangDis/

Examples of Therapy Resources

Black Sheep Press: Talkabout Friends, Talkabout School, Practical Pragmatics:
www.blacksheeppress.com
Fun Decks: Emotions, Multiple Meanings: www.superduperinc.com
Introducing Inference (M. Toomey): www.taskmasteronline.co.uk
Schubi Picture Sequences: Tell It, Sentimage, Combimage: www.winslow-cat.
com
Talkabout Activities: Developing Social Communication Skills (A. Kelly):
www.speech-therapy.org
Think It Say It pictures: www.proedinc.com

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170 • Adams

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 7
SOCIAL COMMUNICATION ASSESSMENT
AND INTERVENTION FOR CHILDREN ON
THE AUTISM SPECTRUM
Danai K. Fannin and Linda R. Watson

People are always looking for the single magic bullet that will totally
change everything. There is no single magic bullet.
—Temple Grandin, PhD

LEARNING OBJECTIVES
Readers will be able to
1. Specify the current incidence and prevalence of Autism Spec-
trum Disorders (ASD).
2. Describe the most recent adjustments in ASD diagnosis using
the new DSM-5 criteria and their ramifications on Asperger’s
Disorder (ASP) diagnosis.
3. Differentiate between ASP and ASD.
4. Describe referral guidelines and recommended medical and
educational assessment practices.
5. Define the level of evidence for current treatment approaches for
ASD across the lifespan and various environments (e.g., home,
classroom).
Hanaa is a 6-year, 3-month-old girl who presented with a medical diag-
nosis of severe autism. She lives with her parents, Mr.  and Mrs.  A, two

171
172 • Fannin and Watson

older sisters (10 years old and 8 years old, respectively), and one younger
sister (aged 4 years), with both Arabic and English spoken in the home.
Mr. A works while Mrs. A stays at home. At her first birthday, Hanaa was
able to say “mama” and “baba” but stopped saying words at 18 months of
age. Mr. and Mrs. A became concerned about Hanaa’s communication dif-
ficulties at the age of 2 years, 6 months. At age 4 year, Hanaa’s pediatrician
referred her to a university speech-language pathology clinic for an evalu-
ation. She had been receiving language treatment at school with the goals
of expanding functional communication, reciprocal interaction, com-
menting, advocating for self-help, and repairing communication break-
downs. At the time of referral, Mr. and Mrs. A believed she understood
commands but had difficulty vocalizing her wants and needs. Instead, she
became quiet or angry when she was not understood. Hanaa expressed
her needs by leading people to what she wanted, pointing to objects, or
bringing objects to others. Of the few words she had, some were in English
(e.g., one, two, three) and some were in Arabic (e.g., sayyāra [car]); Mr. and
Mrs. A reported that she rarely interacted with her family socially.
Hanaa also had sleep disturbances and feeding delays, prompting
Mr.  and Mrs.  A  to feed her and give her an over-the-counter supple-
ment to help her sleep. She could drink from a cup but had strong food
preferences. In fact, Hanaa was hospitalized for 12 days after she went
3 days without eating or drinking. Additionally, Hanaa had been taken
to the emergency room on a number of occasions for ear infections and
accompanying fevers.
The evaluating Speech-Language Pathologist (SLP) observed play
sessions between Mrs. A and Hanaa, and Mrs. A seemed comfortable
playing with her daughter. However, Hanaa was difficult to engage in
play routines because of her sensory-seeking behaviors (e.g., running
around the room and climbing on cabinets). While the SLP attempted
to play with Hanaa, she exhibited self-stimulating behaviors such as
mouthing objects and spinning in circles when looking into the mirror.
She did not produce intelligible vocalizations, respond to vocalizations,
respond to her name, or seek eye contact. Hanaa sometimes extended
her arm to show an object, sometimes gave an object, and often raised
her arms to request being picked up. Hanaa consistently displayed play
skills corresponding to the Functional Play level (Indiscriminate Actions
to Combinations) and inconsistent, emerging Pre-Symbolic Play behav-
iors with maximum prompting from an adult (Bakeman & Adamson,
1984). Hanaa demonstrated proto-imperative communication func-
tions by lifting her hand in a palm-up position (request) and pushing
an adult’s hand away (protest). Hanaa did not consistently demonstrate
proto-declarative (i.e., showing something to get attention) functions,
 Children on the Autism Spectrum • 173

and she did not point to share interesting objects or events. When con-
sidering joint engagement, Hanaa was at the Object-Engaged level of
joint engagement states (Bakeman  & Adamson, 1984), when she pri-
marily focused on objects during parallel play.
After a 12-week program designed to increase Hanaa’s joint atten-
tion/joint engagement, Mrs. A reported improvement in Hanaa’s social
interaction with her sisters and acquisition of some additional words.
At age 6, however, Hanaa returned to the clinic, and the SLP provid-
ing treatment reported limited communication skills and persistent
sensory-seeking behaviors.
This case exemplifies different issues in assessment and intervention
planning for people with Autism Spectrum Disorder (ASD), including
persisting core deficits after treatment, cultural differences in family lan-
guage use, and sensory integration impairments that affect behavior and
feeding. Hanaa demonstrates developmental delays in language, play skills,
social skills, and joint attention, as well as repetitive behaviors. Because of
the difficulty in treating functionally nonverbal people with severe autism,
these individuals frequently are excluded from treatment studies. Further-
more, those from culturally and linguistically diverse (CLD) backgrounds
are even more absent from ASD research (Pierce et  al., 2014). Both of
these factors (i.e. nonverbal, bilingual environment) might contribute to
why treatment for Hanaa has not yet been as effective as desired. A com-
bination of treatment strategies at an increased dose, reduction of sen-
sory seeking behaviors, and the addition of Augmentative and Alternative
Communication (AAC) methods might be the answer for some nonver-
bal children such as Hanaa who do not initially respond to treatment.
Research concerning evidence-based practice for ASD is still needed,
and indeed, such research is ongoing. The following chapter describes
the current state of evidence for diagnostic assessment and communi-
cation/social interaction treatment of ASD across settings and the life-
span. Because reviews of evidence were conducted before the advent
of the new DSM-5 diagnosis of ASD, other terms (e.g., Autistic Disor-
der [AD]), Pervasive Developmental Disorder Not Otherwise Specified
(PDD-NOS), high-functioning autism, autism) utilized in individual
studies and resources will be used throughout the chapter. Because of
the multiple names used for Asperger’s Disorder (e.g., Asperger Disor-
der, Asperger Syndrome, Asperger’s Syndrome, Asperger’s syndrome)
the term Asperger’s Disorder (ASP) will be used.
Multiple systematic evidence reviews have been conducted related to
different aspects of detection, diagnosis, and treatment of individuals
with ASD. We make use of those sources throughout this chapter,
while offering two general cautions to readers. First, different evidence
174 • Fannin and Watson

reviews use different criteria for the types of studies that will be included
in a review; for example, in the evidence synthesis of ASD interven-
tions issued by the Agency for Healthcare Research Quality (Warren
et al., 2011), studies of behavioral treatment with fewer than 10 partici-
pants and those that did not aggregate results across participants were
excluded, leading to the exclusion of a large body of research on interven-
tions for individuals with ASD that has used single case designs, whereas
the National Autism Center (NAC; 2009) included single-case design
studies in its evidence synthesis. Second, evidence syntheses, which are
tremendously useful to practitioners, are inevitably “out-of-date” by the
time they are published, because these projects require searching a body
of literature using a cutoff date, followed by the complex process of ana-
lyzing, synthesizing, and disseminating that evidence. In the meantime,
new studies are being published that can strengthen, clarify, or, in some
cases, contradict the evidence previously available.

DEFINITIONS, INCIDENCE, AND PREVALENCE

ASD is a developmental disability distinguished by early emerging core
deficits in social interaction and communication that affects develop-
ment into adulthood (Howlin, 1997). The following core deficits differ-
entiate children with ASD from typically developing children and other
developmental delays with similar characteristics: (a) joint attention
(i.e., actively sharing and following the attention of others by coordinat-
ing attention to people, events, or objects), (b) social communication
(i.e., various nonverbal and verbal skills necessary for reciprocal social
interaction and development of peer relationships), and (c) repetitive
behaviors (i.e., stereotyped motor mannerisms, narrow interests, fixa-
tion on parts of objects, and/or rigidity of routines): (Mundy, Sigman,
Ungerer, & Sherman, 1986; Volkmar, Lord, Bailey, Schultz, & Klin, 2004;
Wetherby, Watt, Morgan, & Shumway, 2007).
The pathophysiology of this neurological disorder has not yet been
fully determined; it is likely multifactorial and variable from one indi-
vidual with ASD to the next (Parellada et  al., 2014). For this reason,
behavioral and educational interventions have been most frequently
used to target the core symptoms of ASD, rather than administration
of biomedical treatments (NAC, 2009). Research now indicates that the
prevalence of autism and related disorders in the United States may be as
high as 1 in 68 children (Autism and Developmental Disabilities Moni-
toring Network, 2014), and up to 1 in 50 school-age children (Blum-
berg et al., 2013), exceeding the prevalence of other severe childhood
 Children on the Autism Spectrum • 175

developmental disorders. Approximately 500,000 children and ado-

lescents are estimated to meet criteria for ASD, making it a significant
public health concern (Mandell, Cao, Ittenbach, & Pinto-Martin, 2006).
Fewer prevalence studies have been conducted internationally and
numbers are presented with the caveat that there were methodologi-
cal problems (e.g., low sample size) with the gathering of data. Studies
conducted in the countries of Oman, Israel, France, Indonesia, Iceland,
China, and Portugal report low prevalence of 1.4 per 10,000 children, 10
per 10,000, 5.35 per 10,000, 11.7 per 10,000, 13.32 per 10,000, 16.1 per
10,000, and 16.7 per 10,000, respectively (Hughes, 2011). Other countries,
including Canada, Australia, Sweden, Denmark, and Brazil report higher
prevalence of 64.9 per 10,000, 39.2 to 51 per 10,000, 72.6 per 10,000, 68.5
per 10,000, and 27.2 per 10,000 respectively. When the United States prev-
alence is translated to 10,000 children, the number is approximately 113
per 10,000, which is more consistent with countries like the United King-
dom (94 per 10,000), and Japan (181.1 per 10,000). Most of these interna-
tional studies are recent but some date as far back as 1992. Thus, based on
current prevalence in the United States and the more recent international
studies, the numbers in those earlier studies have likely risen.
Although there are no known differences in ASD incidence by race,
socioeconomic status (SES), nationality, or ethnicity, Dyches, Wilder,
Sudweeks, Obiakor, and Algozzine (2004) suggest that cultural fac-
tors may influence: (a) how and when symptoms of ASD are defined
and viewed, (b) to what extent stigma of disability status exists across
cultures, and (c) if there are differences in how families accept ASD diag-
noses. Clinician bias may also play a role in how certain cultures diag-
nose and treat ASD. People from various backgrounds may face unique
obstacles when managing disability but there is a lack of research on
how culture may affect treatment outcomes. Thus, until more research
on assessment and intervention for those from CLD backgrounds is
conducted, clinicians must bear in mind that populations that have pro-
vided evidence for best practices in ASD have primarily employed sam-
ples of middle-SES people of European descent (Dyches et  al., 2004).
Because of the increased number of people identified with ASD, the
urgency to meet the needs of all families with ASD has been heightened.

CHARACTERISTICS OF ASD AS DEFINED BY THE DSM-5

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a
diagnostic guide for mental illnesses used by social workers, research-
ers, physicians, psychologists, and those in forensic fields (Kupfer,
176 • Fannin and Watson

Regier, & Kuhl, 2008). In the previous version of the DSM (4th ed., text
rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000), the
umbrella category of “Pervasive Developmental Disorders” included
several distinct diagnoses. Individuals with the most symptoms and
most classic symptoms were classified as having Autistic Disorder (AD).
Those with intelligence and adaptive functioning within normal limits
and no history of extreme language delay were likely to meet the criteria
for ASP. The rare group of children who developed relatively typically
for the first 2 to 5 years followed by progressive developmental deterio-
ration and the development of social, affective, and repetitive behaviors
were diagnosed with Childhood Disintegrative Disorder. The diagno-
sis of Rett’s Disorder was also based on a pattern of very early normal
psychomotor development followed by the loss of motor skills, decel-
eration of head growth, severe impairments in receptive and expressive
language, and a loss of social engagement early in development (often a
transient symptom). Finally, individuals who did not meet the criteria
for one of the aforementioned diagnoses and showed deficits in social
reciprocity similar to those seen in AD were diagnosed with PDD-NOS.
Using this system, diagnosticians have been reliably distinguishing peo-
ple on the autism spectrum from those who are typically developing or
those with other disorders. Differentiation among the various pervasive
developmental disorders has not been as consistent and valid across set-
tings and diagnosticians, however (Borden, 2011). For this and other
reasons, a revision of diagnostic criteria was needed to more rigorously
confine diagnosticians to the features of “autism spectrum disorder” and
characterize other factors such as intelligence, language level, or severity
as continuously variable, rather than categorical features (APA, 2013).
In May 2013, the fifth edition of DSM (APA, 2013) was published with
anticipated and controversial changes to the autism diagnosis. The DSM-5
manual incorporates the previous diagnoses of AD, ASP, and other Per-
vasive Developmental Disorders into the single diagnosis of ASD (Bor-
den, 2011). Diagnosis is based on symptoms in two broad domains:
social-communication and restrictive/repetitive behaviors. A  diagnosis
of ASD under DSM-5 entails specifying the severity of symptoms in each
of these domains, as well as an indication of whether there is accompany-
ing intellectual impairment, language impairment, and/or known genetic
or medical factors or environmental conditions. The public, composed
of parents, individuals on the autism spectrum, and health care workers
have raised concerns about the new definition of ASD, especially regard-
ing the elimination of ASP and PDD-NOS as distinct diagnoses (Ghazi-
uddin, 2010; Kite, Gullifor, & Tyson, 2013; Leventhal-Belfer, 2012).
Concerns have included the possibility that an ASD diagnosis would
be stigmatizing for those with milder symptoms and parents would
 Children on the Autism Spectrum • 177

therefore be less likely to pursue an evaluation for mildly affected chil-

dren (Kite et al., 2013) or, conversely, that the DSM-5 criteria are too
strict and would exclude people with milder, high-functioning autism,
especially females (Frazier et  al., 2012). Research, however, indicated
that the DSM-5 was valid in Phase I field trials with 97% specificity, but
81% sensitivity that prompted a suggested relaxed algorithm in Phase
II field trials to catch 12% of people with ASD who may potentially be
missed (Frazier et al., 2012). Further, supporters of the revision found
that the poor prognoses for functional outcomes in adults with AD and
PDD-NOS appear to be similar for degree of disability and marital sta-
tus (Mordre et al., 2012). This finding reinforces the importance of indi-
viduals with milder symptoms continuing to meet the criteria for ASD,
thereby allowing access to services.

ASPERGER’S DISORDER
ASP is a developmental disorder that has an impact on one’s social skills
and ability to communicate effectively, despite cognitive and language
skills being within the normal range. Persisting interests in specific sub-
jects and social awkwardness are two characteristics typical of ASP. In
the DSM-IV-TR (APA, 2000), the primary feature distinguishing ASP’s
from AD was the absence of childhood language delays, resulting in ASP
being differentiated from AD solely based on early language develop-
ment (Bennett et al., 2008; Cuccaro et al., 2007). Indeed, several research
reviews have concluded that individuals with ASP show quantitative but
not qualitative differences from those with high-functioning autism
(i.e., AD with IQs within the normal range), and therefore, ASP should
be considered a variant of autism rather than a distinct disorder (Frith,
2004; Sanders, 2009). Furthermore, in light of the controversies over no
longer distinguishing ASP’s from AD in the DSM-5, it is important to
recognize that the criteria for ASP in the Diagnostic and Statistical Man-
ual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Asso-
ciation, 1994) and Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000)
were also widely criticized (Klin, McPartland & Volkmar, 2005).
Historically, DSM criteria have been very influential, but other
diagnostic classification systems also are used, with widespread global
reliance on the World Health Organization’s (WHO’s) International
Classification of Diseases-10 (ICD-10), currently in its 10th edition.
The ICD-10 (WHO, 1996) diagnostic criteria for Pervasive Develop-
mental Disorders were closely aligned with those in the DSM-IV-TR.
Work on the ICD-11 is currently underway, but the extent to which it
will be aligned with the DSM-5 is not yet clear.
178 • Fannin and Watson

REFERRAL GUIDELINES
The first professionals with opportunities to notice signs of communica-
tion disorders are often family practitioners or pediatricians. The Ameri-
can Academy of Pediatrics (AAP) recommends screening for all at the
ages of 9 months, 18 months, and 24 to 30 months, using a standardized
tool and surveillance for ASD at every well-child visit (Centers for Disease
Control and Prevention [CDC], 2013; Johnson, Myers, & the Council on
Children with Disabilities, 2007). Surveillance includes listening care-
fully to parents, maintaining a developmental history, making informed
observations, identifying risk and protective factors, and documenting
the process and findings. The American Academy of Neurology and the
Child Neurology Society practice parameter on autism identifies several
symptoms that should trigger an immediate referral (Filipek et al., 2000):
• By 12 months of age, the child is not babbling, pointing, or
using other gestures.
• By 16 months the child has no single words.
• By 24 months the child has no two-word phrases.
• The child loses language skills at any age.
If any of the following risk factors are present during the birth to
three-year age range, an ASD screener should be administered (see
Table 7.1). If multiple of the following risk factors are present, however,
the child can be referred directly for a comprehensive assessment (i.e.,
an ASD screening is not necessary; Johnson et al., 2007):
• There is an older sibling diagnosed with ASD.
• An adult knowledgeable about child development has a concern
that the child may have ASD.
• The child seems as if he or she cannot hear, despite a normal
hearing evaluation.
• The child lacks joint attention gestures.
• The child shows idiosyncratic repetitive behaviors (e.g., fixation
on certain objects, hand flapping, self-injury, perseveration on
certain topics).
• The child has inappropriate or delayed play behaviors.
• The child uses delayed or immediate echolalic verbalizations
and/or has delayed receptive language.
Signs of ASD are often observable by 12 months of age and knowledge-
able and experienced clinicians can reliably diagnose ASD in many
children as early 24 months (American Speech-Language-Hearing Asso-
ciation [ASHA], 2006). Despite the fact that ASD-sensitive screeners for
children as young as 9 months exist, many children are not identified
 Children on the Autism Spectrum • 179

until years later (Mandell et al., 2010). In fact, the median age for ini-
tial ASD diagnosis in the United States is around 53 months, and even
for children who meet the DSM-IV-TR criteria for AD, the median age
is a relatively old 48 months (Autism and Developmental Disabilities
Monitoring Network, 2014). Thus, continued vigilance for symptoms
that would indicate screening or assessment is important.
Children with ASD who remain unidentified at school age are often
those with good language and cognitive skills. The following behaviors
in the primary grades should trigger screening or referral to a psycholo-
gist, SLP, or primary-care provider (Reilly, Campbell, & Keran, 2009):
• Abnormal intonation and/or rhythm of connected speech.
• Voice volume too soft or loud.
• Difficulty with back-and-forth conversation, despite age-
appropriate language structure.
• Discrepancy between academic ability and “social intelligence,”
particularly during unstructured social interactions.
• Little interest in other children.
• Difficulty joining play appropriately (e.g., hitting, interrupting
without asking to play).
• Difficulty developing and maintaining relationships, especially
with same-age peers.
• Lack of awareness of personal space, and/or marked intolerance
for intrusions of others into his or her personal space.
• Failure to understand sarcasm or metaphor.
• Unusually intense and focused preoccupation with an interest;
may involve collecting, listing, or numbering.
• Persistent difficulties in coping with change.

SCREENING
While there has been considerable research on ASD screening tools, the
most recent systematic review rated the quality of evidence as low for
most available tools (National Institute for Clinical Excellence [NICE],
2011). Meisels (1989) recommends that both sensitivity and specific-
ity of developmental screening tools for young children be at least 80%,
whereas Barnes (1982) considers sensitivity in the 70% to 80% range to
be adequate for developmental screening. Table 7.1 lists ASD screening
tools reviewed by several sources for quality of evidence, along with infor-
mation on specificity and sensitivity. The NICE evidence ratings should
be considered conservative, because they only apply to studies published
between 1990 and 2010 and thus do not reflect more recent studies.
 RECOMMENDED MEDICAL AND
EDUCATIONAL ASSESSMENT

Table 7.1 Evidence-Based ASD Screeners

Screeners Type of Evidence Ages

Modified Checklist for Autism Very Low Qualityb 16–30 months

in Toddlers (M-CHAT; Robins, 74% Sensitivityb
Fein, Barton, & Green, 2001)a 42% Specificityb
Communication and Symbolic No studies met criteria 6–24 months
Behavior Scales–Developmental for evidence reviewb
Profile (CSBS-DP) 88.9% Sensitivity/Speci-
Infant-Toddler Checklist (ITC; ficityc
Wetherby & Prizant, 2002)
Screening Tool for Autism in No studies met criteria 24–36 months
Two-Year-Olds (STAT; Stone, for evidence reviewb
Coonrod, & Ousley; 2000; 92% Sensitivityc
Stone, Coonrod, Turner, & 85% Specificityc
Pozdol, 2004; Stone & Ousley,
1997)
Social Communication Very Low Qualityb 4–40 years*
Questionnaire (SCQ; Rutter, 71% Sensitivityb
Bailey, & Lord, 2003). 62% Specificityb
Checklist for Autism in Tod- No studies met criteria 18–24 months
dlers (CHAT; Baird et al., 2000; for evidence reviewa,b
Baron-Cohen, Allen, & Gillberg, Strong Evidenced
1992; Baron-Cohen, et al., 38% Sensitivityc
1996). 98% Specificityc

Note. Research designs designated as “Very Low Quality” evidence were uncontrolled
observational studies.
a
A new version of this tool, the Modified Checklist for Autism in Toddlers, Revised with
Follow-up (M-CHAT-R/F; Robins, Fein, & Barton, 2009) is now available and recom-
mended by the authors.
b
Rated by the National Institute for Health and Clinical Excellence (NICE, 2011).
c
Rated by the American Speech-Language-Hearing Association (ASHA, 2006). “Strong
Evidence” defined as two or more studies that had adequate evidence of efficacy, at least
moderate applicability to the topic, and evidence that consistently and strongly support-
ed the recommendation.
d
Rated by the New York State Department of Health, Early Intervention Program
(NYSDH, 1999).
* Can be used for children as young as 24 months but evidence exists for 4+ years old
(one study included children with intellectual disability).
 Children on the Autism Spectrum • 181

RECOMMENDED ASSESSMENT PRACTICES

If a screener and/or clinical observation indicate risk for ASD, a full
evaluation should be conducted. The evaluation protocol should not
rely on standardized ASD tools exclusively. Rather, it should include
measures of the function of behaviors, cognition, adaptive behavior,
play, motor skills, language, and concomitant mental conditions (Boyd,
Conroy, Asmus, McKenney,  & Mancil, 2008; Taylor-Goh, 2005). All
of these areas of assessment are needed to (a) differentiate ASD from
other disorders with similar symptoms (e.g., Specific Language Impair-
ment, Social [Pragmatic] Communication Disorder), (b) determine
ASD severity, and (c) specify accompanying impairments (e.g., intel-
lectual impairment, language impairment, medical or genetic condi-
tion, behavioral disorder, catatonia, mental disorder). However, there
is no evidence that these additional assessments produce a more accu-
rate ASD diagnosis. Instead, information derived from a comprehen-
sive assessment protocol provides a more detailed explanation of the
client’s behaviors, aiding development of a more needs-based manage-
ment plan (NICE, 2011).
The collaborative work of a multidisciplinary team can make the
diagnostic process more complete and efficient from the perspec-
tive of the family. The composition of multidisciplinary autism
teams in health care settings varies but may include a psychologist,
a psychiatrist or developmental pediatrician, an SLP, an Occupa-
tional Therapist (OT), a Developmental Therapist (DT), a Physical
Therapist (PT), and a neurologist. Depending on the findings and
the expertise represented on the team, an individual may be
referred for further evaluation, such as genetic testing and DNA
analysis to check for conditions such as Fragile X. Multidisciplinary
autism teams are not universally available; thus, individuals may
be diagnosed with ASD by one professional, often a psychiatrist or
clinical psychologist. Nonmedical diagnoses of ASD can be made in
schools and other clinical settings. In schools, diagnostic teams may
include a school administrator, an SLP, an OT, a PT, a school psy-
chologist, and a DT when available. An educational diagnosis can
serve the purpose of qualifying the child for services in schools even
if the child does not have a medical diagnosis (ASHA, 2006). In early
childhood and school settings, an arena type assessment where all
evaluators simultaneously observe the child communicating, play-
ing, problem solving, and participating in other tasks may be con-
ducted but many early intervention programs or educational settings
182 • Fannin and Watson

do not allow for schedules to be coordinated among all evaluators.

Thus, the child may be assessed at different times by individual pro-
fessionals who then convene at an Individual Family Service Plan
(IFSP)/Individual Education Program (IEP) meeting to determine
eligibility and plan services.
In a systematic review spanning 2000 to 2012, Falkmer, Anderson,
Falkmer, and Horlin (2013), determined that the gold standard of ASD
evaluation consists of a multidisciplinary team combining the Autism
Diagnostic Observation Schedule (ADOS; Lord et al., 2000) and Autism
Diagnostic Interview–Revised (ADI-R; Le Couteur, Lord, & Rutter,
2003; which has the best accuracy levels at 80.8%), other assessments,
and clinical judgment. The creators of the ADOS and ADI-R stress that
these should not be the only tools used to make diagnostic decisions but,
instead, should be used as part of a comprehensive assessment protocol.
By combining information from assessment tools, parent/teacher report,
observation, and clinical judgment, professionals can diagnose autism
based on ICD-10 and DSM-5 criteria (Scottish Intercollegiate Guidelines
Network [SIGN], 2007). Standardized evaluation tools are still being vali-
dated and developed, and not all tools in regular use have been deemed
evidence based. Using the Appraisal for Guidelines in Research Evalua-
tion II (AGREE II) Framework (Brouwers et al., 2010) that was adopted
by most North American and European countries in 1990, the National
Center for Evidence-Based Practice in Communication Disorders
(N-CEP) scored various ASD assessment guidelines for their scientific
rigor, categorizing them as Highly Recommended, Recommended with
Provisos, and Not Recommended (ASHA, 2009). Table 7.2 presents spe-
cific assessment tools for adults and children with ASD that were found
in Highly Recommended guidelines and, therefore, have the most rig-
orous evidence. The NICE (2011) guidelines highlight assessment tools
with evidence of sensitivity and specificity at a minimum of 80%, with
the lower 95% confidence interval estimate above 70%. These tools also
align with the ICD-10 and DSM-5, from which the medical diagnosis
and diagnostic codes are derived.

EVIDENCEBASED INTERVENTION FOR AUTISM

SPECTRUM DISORDERS ACROSS THE LIFE SPAN
Despite the fact that one must meet specific criteria to be diagnosed
with ASD, considerable heterogeneity of behaviors, background factors,
and presentation of symptoms exists within the population. Interven-
tion studies have rarely compared two well-specified treatments or
Table 7.2 Highly Recommended Guidelines for ASD Assessment Tools
Diagnostic Tools Type of Evidence Ages Studied
Autism Diagnostic Interview-Revised (ADI-R; Le Very Low Qualitya Adults with and without learning dis-
Couteur, Lord, & Rutter, 2003) Low Qualitya ability
Gold standardb Children with intellectual disability
Limited Evidencec 12+ months
Autism Behavior Checklist (ABC; when used with Very Low Qualitya School age
other diagnostic tools; Krug, Arick, & Almond, Strong Evidencec Not recommended under 3 yearsc
1980)
Ritvo Autism Asperger Diagnostic Scale–Revised Very Low Qualitya Adults with no learning disability
(RAADS-R; Ritvo et al., 2011).
Adult Asperger Assessment (AAA) (includes Very Low Qualitya Adults with no learning disability
Autism-Spectrum Quotient [ASQ] and Empathy
Quotient [EQ]; Baron-Cohen, Wheelwright, Rob-
inson, & Woodbury-Smith, 2005)
Autism Diagnostic Observation Schedule Very Low Qualitya Adults with learning disability
(ADOS-G; Lord et al., 2000)
Autism Diagnostic Observation Schedule Low Qualitya Preschool
(ADOS-2; Lord, Rutter, DiLavore, Risi, & Gotham, Very Low Qualitya Children with intellectual disability
2012) Good accuracy and correspondence
with DSM/gold standardb
Childhood Autism Rating Scale (CARS; Strong Evidencec Early childhood, preschool
Schopler, Reichler, & Rochen Renner, 1999) Good for autism but not other ASDsb

(Continued )
Table 7.2 (Continued )
Diagnostic Tools Type of Evidence Ages Studied
Parent Interview for Autism (PIA; Stone & Hogan, No study met inclusion criteria for 2–4 years
1993). reviewa
Strong Evidencec
Diagnostic and Statistical Manual (4th ed, text rev; Very Low Qualitya Diagnosed under 24 months and up to 36
DSM-IV-TR; APA, 2000); Diagnostic and Statisti- Low Qualitya months (99% of children <24 months re-
cal Manual (5th ed.; DSM-5; APA, 2013). Gold standardb tained autism diagnosis a year later, 100%
International Classification of Diseases (ICD-10). Limited Evidencec with another ASD retained diagnosis a
(WHO, 1996) year later, but 41% thought not to have
ASD did indeed have it a year later)
(95% of children <24 mo. retained autism
diagnosis a year later, 84% with another
ASD retained diagnosis a year later, and
0% thought not to have ASD did indeed
have it a year later)

Note. Research designs Note. Research designs designated as “Very Low Quality” evidence were uncontrolled observational studies. “Low Qual-
ity” evidence were controlled observational studies.
a
Rated by the National Institute for Health and Clinical Excellence (NICE, 2011).
b
Rated by the American Speech-Language-Hearing Association (ASHA, 2006). “Strong Evidence” defined as two or more studies that had
adequate evidence of efficacy, at least moderate applicability to the topic, and evidence that consistently and strongly supported the recom-
mendation.
c
Rated by the New York State Department of Health, Early Intervention Program (NYSDH, 1999).
 Children on the Autism Spectrum • 185

investigated the implications that heterogeneity among individuals with

ASD has in response to an intervention; thus, even when a treatment
has good evidence for efficacy, we cannot assume it will work well for all
with ASD. Unfortunately, many clinicians, researchers, and caregivers
have claimed that their treatment of choice has been proven successful
(Prelock & McCauley, 2012), ignoring the complexities of evaluating the
evidence for interventions tested with this population.
The complexities of evaluating evidence extend to systematic reviews
of ASD treatments. First, organizations that sponsor reviews have
had various foci, leading to inconsistencies in interventions selected
across reviews. For example, the National Autism Center (with many
members who are behavior analysts who research autism treatments
specifically) included studies of ASD treatment only. Therefore, several
studies from certain areas (e.g., occupational therapy and physical ther-
apy) were excluded from the NAC (2009) review because these studies of
sensory processing or motor skill treatments tend to include other dis-
abilities beyond ASD. Additionally, the Agency for Healthcare Research
and Quality (AHRQ; Warren et al., 2011) report excludes some research
on Applied Behavioral Analysis (ABA) treatments because these treat-
ments did not meet their quality/strength of research criteria, while other
reviews included ABA studies (Missouri Autism Guidelines Initiative,
2012). As another example, the National Professional Development Cen-
ter’s (NPDC) report (Odom, Collet-Klingenberg, Rogers, & Hatton, 2010)
only contains Focused Behavioral Interventions, thereby excluding Com-
prehensive Behavioral Treatments. Second, time spans of the reviews vary
from 1957 to 2007 (NAC, 2009) to more recent research from 2000 to
2010 (Warren et al., 2010). Thus, the number and era of studies reviewed
are not identical. Third, the reviews varied in their classification of
evidence-based practice where some only reported studies meeting their
evidence of effectiveness criteria, while others placed the studies in contin-
uous categories such as established, emerging, or unestablished. Last, some
reviews grouped treatments into “packages” (e.g., Behavioral Packages,
Antecedent Packages) while others identified treatments individually.
These varying intervention classification methods appeared to indicate
differences in findings at first glance, but when comparing across reviews
while taking the semantically different classifications into account, deter-
minations of which treatments were evidence based were not found to
be considerably different (Missouri Autism Guidelines Initiative, 2012).
There is continuing consensus that guidelines for best ASD inter-
vention practices should include (a) early intervention; (b) systematic,
developmentally appropriate activities and learning opportunities;
(c) intensive instruction with active engagement; (d) peer and family
186 • Fannin and Watson

involvement for generalization and educational achievement; (e) indi-

vidualized services and supports via an IEP; (f) a systematic process
for measuring outcomes; and (g) structured environments for learn-
ing (Iovannone, Dunlap, Huber,  & Kincaid, 2003; National Research
Council [NRC], 2001). Development of treatment for ASD is steadily
advancing and, although all treatments discussed in this chapter may
not have established effectiveness, several have shown promising results
for positive outcomes. For the purposes of this chapter, interventions
that meet the higher levels of evidence, established or emerging, accord-
ing to the National Autism Center’s (2009) National Standards Report,
will be described:
• Established: Adequate evidence exists to confidently deter-
mine that the treatment results in beneficial effects for those
with ASD.
• Emerging: One or more studies imply beneficial effects for those
with ASD but more high-quality, scientifically rigorous stud-
ies are needed to reliably confirm positive outcomes before it is
determined that the treatment is effective.
For other systematic reviews of ASD interventions, readers may refer to
the Clinical Resources section at the end of this chapter. Because of the
plethora of treatments that have been studied with this population, this
section is divided into comprehensive treatment programs, structural
or peer-based programs, and focused intervention programs. The pur-
pose will be to summarize the evidence base for these programs, while a
more detailed description of the interventions themselves can be found
in individual articles referenced in the chapter, or Prelock and McCau-
ley’s (2012) textbook on ASD treatment.

Comprehensive Treatment Programs

Comprehensive programs address goals across different domains of
development and functioning, and usually can be applied across several
settings (e.g., school, home, individual settings); most have accompany-
ing manuals, trainings, and/or certifications. The next segment of the
chapter provides descriptions of behavioral, naturalistic, and structural
and peer-based programs within comprehensive programs.

Behavioral Packages
Interventions using ABA principles are characterized by a common
chain of events: (a) the occurrence of a stimulus for a desired behavior,
(b) the client demonstrating a response, and (c) the interventionist giving
a verbal or tangible reinforcer if the response is correct or withholding
 Children on the Autism Spectrum • 187

the reinforcer and assisting the client if the response is incorrect. One of
the most extensively studied treatments for ASD, Behavioral Packages
are at the established level of evidence for improvement of academic,
interpersonal, communication, learning readiness, personal respon-
sibility, self-regulation, and play for people from birth to 21 years old
(Birnbrauer  & Leach, 1993; Lovaas, 1987; Matson, Matson,  & Rivet,
2007; NAC, 2009; Reichow & Volkmar, 2010; Stahmer & Schreibman,
1992). They also have been found effective in reducing problem behav-
iors, Restricted, Repetitive, Nonfunctional Patterns of Behavior and
improving Sensory or Emotional Regulation (Iwata, Dorsey, Slifer, Bau-
man, & Richman, 1982; NAC, 2009).
Although behavioral interventions have the most evidence of effec-
tiveness, a number of concerns have been raised. The studies have pri-
marily included verbal participants with a verbal treatment delivery, so
the treatments have not been proven to be as effective with those who
are nonverbal (Walton & Ingersoll, 2013). Many intervention programs
using ABA principles have relied largely on the use of adult-directed,
highly structured discrete trial training strategies, and those interven-
tions have often failed to demonstrate generalization of skills across set-
tings (Wetherby & Woods, 2006, 2008). Much of the research has used
single-case design methods, which have strong internal validity but
unknown external validity (i.e., generalizability to individuals with dif-
ferent characteristics from those studied). Finally, evidence that Behav-
ioral Packages are effective in addressing social pragmatic deficits is
lacking. Although ASP is no longer considered separate from ASD, find-
ing evidence-based treatment for those with Asperger phenotypes is of
utmost importance, especially for interventionists who use only behav-
ioral intervention, as they would be implementing a treatment that lacks
evidence for those with primarily social pragmatic deficits (Wilczynski,
Rue, Hunter, & Christian, 2012). Due to these drawbacks, researchers
have tested more naturalistic applications of ABA principles, such as
Pivotal Response Training (L. Koegel, Camarata, Valdez-Menchaca, &
Koegel, 1998; see below), and clinicians have customized treatments to
individual clients by modifying their behavioral methods to include ele-
ments from developmental approaches that have more evidence of gen-
eralizability (Wilczynski, 2012).
Challenging behavior (e.g., tantrums, hitting, shouting) is common
not only for people with ASD but anyone who has difficulty communi-
cating. Until one is taught to make requests and regulate others’ behav-
ior, challenging behavior will likely replace functional communication.
Thus, Functional Communication Training (FCT) is an interven-
tion based on ABA principles that is designed to teach caregivers to
188 • Fannin and Watson

determine the purpose of the challenging behavior, choose a more appro-

priate way to communicate this purpose, and teach the individual how
to replace the challenging behavior with the appropriate communica-
tion strategy by gradually reducing reinforcements or prompts (Durand,
1990, 2012). When a challenging behavior is dangerous to the person
with ASD or others, however, ensuring elimination of dangerous chal-
lenging behavior may be prioritized over teaching appropriate replace-
ment behaviors for effective communication (Durand, 2012).
In 2009, Petscher, Rey, and Bailey conducted a meta-analysis of at least
80 FCT studies targeting reduction of a variety of challenging behaviors.
Results indicated positive effects and few adverse effects for these par-
ticipants of various ages and impairments. For ASD specifically, how-
ever, Wong et al. (2014) analyzed 12 single-case FCT studies for social,
behavior, communication, play, adaptive skills, and school-readiness
outcomes for participants between 3 to 18  years old. Some of those
studies showed that Response Milieu (provision of opportunities for the
client to make choices) and practicing desired functional communica-
tion in settings outside the therapy room facilitated generalization of
communication skills and augmented the effects of FCT (Carlson, Lui-
selli, Slyman, & Markowski, 2008; Durand, 1990, 2012; Dyer, Dunlap, &
Winterling, 1990; Stokes, Fowler, & Baer, 1978; Watanabe & Sturmey,
2003). Moreover, the NAC (2009) categorizes FCT as a Behavioral Pack-
age, which is at the established level of evidence for people with ASD and
PDD-NOS, birth to 21 years old.
Early Intensive Behavioral Intervention (EIBI; aka the UCLA Treat-
ment) is a Comprehensive Behavioral Treatment for Young Children
(birth to 9 years old), characterized by 20 to 40 hours of weekly intensive
Discrete Trial Training (DTT; Lovaas, 1977) in the home. Based on ABA
principles, DTT is included among the aforementioned definition of
behavioral interventions, with trials consisting of a stimulus, response,
a consequence or reinforcer, and a brief break (Wilczynski et al., 2012).
The NAC’s (2009) examination of 22 studies found treatments like EIBI
to be effective for increasing communication, higher cognitive func-
tions, interpersonal, motor, personal responsibility, placement, and play
while being effective in reducing problem behaviors. Comprehensive
Behavioral Treatment for Young Children, which includes EIBI, is at the
established level of evidence for children with AD and PDD-NOS.
Specifically, EIBI has produced positive outcomes for expressive lan-
guage, receptive language, socialization, and daily communication skills
(Reichow, Barton, Boyd, & Hume, 2012). The quality of this evidence
has been limited in widespread generalization of results because of the
lack of randomized controlled trials (RCTs) and dosage guidelines. For
 Children on the Autism Spectrum • 189

instance, positive results have been reported for EIBI administered at

as little as 12 hours a week, 25 hours per week, or 40 hours per week
(Eldevik, Eikeseth, Jahr, & Smith, 2006; Luiselli, Cannon, Ellis, & Sis-
son, 2000; Meyer, Taylor, Levin, & Fisher, 2001). Hence, questions about
EIBI dosage remain.
When considering DTT singularly, the NAC (2009) declared it
established for those 3 to 21 years old when targeting communication,
adaptive, and social skills. An RCT showed significantly improved lan-
guage development, IQ scores, academic skills, and visual-spatial skills
when compared to a 5  hours per week, parent-training group (based
on Lovaas et al.’s, 1981, parent program; Smith, Groen, & Wynn, 2000).
These twenty-eight 18- to 42-month-old children with autism and
PDD-NOS all entered the study with IQs between 35 and 75, but the
experimental group participants were more often mainstreamed than
the comparison group was (Wilczynski, 2012). Moreover, Sallows and
Graupner (2005) showed in their RCT (N = 23, mean age = 33 months),
that children who had higher pretreatment IQs had the most improve-
ment in IQ scores. Thus, characteristics such as IQ and mainstreaming
exposure may influence DTT outcomes, necessitating control of these
variables in future research.
In summary, evidence for behavioral interventions is extensive and
a variety of positive outcomes can be attained. Yet, the literature still
lacks methodologically sound RCTs with larger sample sizes. Further-
more, research on mediating factors (e.g., pretreatment IQ, verbal abil-
ity, communication level), maintenance and generalization of acquired
skills, and evidence to support the use of EIBI and DTT for social prag-
matic skills is imperative.

Naturalistic Teaching Strategies

Naturalistic Teaching Strategies (aka Naturalistic Interventions)
encompass treatments that promote functional skills within typi-
cal, developmentally appropriate routines, activities, or settings that
are  natural reinforcers of the targeted skills (Wong et al., 2014). These
social-pragmatic approaches are more child directed, facilitating gen-
eralization to multiple natural settings (L. Koegel, Koegel, Harrower, &
Carter, 1999), but most also identify their foundations in the learning
principles of ABA. A review of 10 single-case design studies of children
with ASD, birth to 11 years old found Naturalistic Interventions to be
effective when addressing behavior, joint attention, play, communica-
tion, social, and academic skills (Wong et al., 2014). Based on 32 studies
that used high quality quasi-experimental group designs, high quality
single subject designs, and RCTs, with outcomes of communication,
190 • Fannin and Watson

interpersonal skills, learning readiness, and play, Naturalistic Teaching

Strategies are at an established level of evidence for children with AD or
PDD-NOS, birth to 9 years old (NAC, 2009). The following treatments
have been classified as Naturalistic Teaching Strategies.
Training and Education of Autistic and Related Communication
Handicapped Children (TEACCH) is an intervention characterized by
a structured teaching environment rich with visual cues (NAC, 2009). It
also incorporates parent involvement with therapists and educators, as
well as broad-spectrum cognitive-behavioral strategies (Lazarus, 1958)
that consider the domains of physical sensation, visual cues, interper-
sonal relationships, and biological factors (Schopler, 1997). This mul-
timodal approach to cognitive-behavior therapy is designed to increase
effectiveness of treatment and generalization of desired behaviors
(Lazarus, 1958).
The structured teaching methodology capitalizes on students’
strengths, and goals based on these strengths are developed for the IEP.
A variety of procedures that depend on predictable schedules, specific
physical organization of a setting, and individualized teaching methods
are combined in the classroom. By customizing these classroom and
instructional features to the cognitive styles of individuals with ASD,
structured teaching aims to make learning, thinking, and understand-
ing easier for them (Mesibov, Shea, & Schopler, 2004; Walton & Inger-
soll, 2013).
Structure may be provided at a very basic level, e.g., by creating an
“object schedule” for a nonverbal child with ASD using objects associ-
ated with each main activity in his classroom day, or at a more sophis-
ticated level by helping a high-functioning adolescent better adapt to
the school environment by using a smartphone calendar and other apps
that provide predictability and organizational supports. Despite the
individualized nature of TEACCH educational plans, research indicates
that TEACCH can positively affect social contact, communication, imi-
tation skills, higher cognitive functions, motor skills, learning readiness,
personal responsibility, and general socialization scores for children up
to 2.5 years after treatment (NAC, 2009; Panerai, Ferrante, & Zingale,
2002; Walton & Ingersoll, 2013).
A recently published study compared preschool classrooms using the
TEACCH approach with ones using a comprehensive peer-mediated
program called LEAP (Learning Experiences and Alternative Program
for Preschoolers and their Parents) as well as with non-model specific
preschool classrooms (Boyd et  al., 2014). This study found that chil-
dren with ASD made progress across an academic year in all three types
of classrooms, but that their progress was the same no matter which
 Children on the Autism Spectrum • 191

type of classroom they were in. In order to be included in the study,

all classrooms had to be rated as “high quality” based on observations
of trained observers using a standardized rating scale. The researchers
suggest that it may have been the many common elements across these
high quality classrooms that were important in promoting student pro-
gress rather than the elements that differentiated among the three types
of classrooms.
The TEACCH program is considered to be at the emerging level of
evidence in the NAC (2009) review because of studies with small sam-
ple sizes and a lack of the most rigorous research design (RCT). In an
updated meta-analysis of research on TEACCH (Virues-Ortega, Julio, &
Pastor-Barriuso, 2013), the authors identified 13 studies for inclusion,
and found moderate to large gains in social behavior and maladaptive
behavior, but small to negligible effects on cognition, verbal, motor, or
perceptual skills. Studies using TEACCH programs varied widely in
terms of the age of the individuals included, whether the program was
applied in home, school, or community settings and the duration and
intensity of the intervention. The relatively small number of studies and
their variability prompted the authors to conclude that the results of
their meta-analysis should be considered preliminary.
Pivotal Response Treatment (PRT) focuses on pivotal areas of devel-
opment including motivation, social initiations, responsivity to multiple
cues, and self-management (L.  Koegel et  al., 1998). Pivotal Response
Treatment has been used successfully with children, adolescents, and
young adults and by concentrating on pivotal areas, change may occur
in behaviors not directly targeted such as increased imitative utterances,
learning rate, speech intelligibility, and eye gaze alternation (Bruin-
sma & McNerney, 2012; R. Koegel & Koegel, 1990; R. Koegel, Vernon, &
Koegel, 2009).
Quasi-experimental, highly controlled studies have found PRT to be
more effective with those who (a) can tolerate the close proximity of
others, (b) demonstrate few nonverbal repetitive behaviors, (c) have a
high level of verbal repetitive behaviors, and/or (d) are interested in toys
(Bruinsma & McNerney, 2012; Scherer & Schreibman, 2005). Hence, as
with DTT, mediating factors play a role in treatment response. Although
PRT is a naturalistic treatment delivery that motivates the child to learn
because they have choices in the play, it is derived from ABA strate-
gies, resulting in its simultaneous categorization as Antecedent Package,
Behavioral Package, and Self-Management treatment types. At its core,
however, PRT is a play-based treatment that has been scientifically vali-
dated, resulting in an established level of evidence for those with ASD, 3
to 9 years old (NAC, 2009).
192 • Fannin and Watson

Interventions like Enhanced Milieu Teaching (EMT) are based on

the therapist- or caregiver–child dyad playing in a naturalistic context
(Kaiser, Hancock,  & Trent, 2007). EMT is designed for children who
have minimal language (i.e., 10 words or Mean Length of Utterance
under 3.0) but can imitate words. For detailed information on EMT, see
Hancock and Kaiser (2012).
Enhanced Milieu Teaching has resulted in increased targeted lan-
guage, and improved quality of caregiver conversational turns with
children with or at risk for ASD as young as 18 months. Studies at the
highest quality (RCT) showed positive results after 24 sessions, that
persisted 6 months later (Hancock & Kaiser, 2002). In summary, EMT
is among the Naturalistic Teaching Strategies that are at the established
level of evidence for the outcomes of communication skills, play, inter-
personal skills, and learning readiness for those birth to 9 years old with
AD and PDD-NOS (NAC, 2009).
The Early Start Denver Model (ESDM; Rogers & Dawson, 2010) is
a comprehensive early intervention approach based on both ABA and
developmental principles. In the initially reported study of ESDM, pro-
fessionals engaged in one-to-one interactions with toddlers with ASD
for 15  hours a week for 2  years, supplemented by parent delivery of
ESDM for an additional 5 (or more) hours per week. ESDM yielded
large effects in improved cognitive developmental outcomes (Dawson
et  al., 2009) after 2  years. This intervention shares many characteris-
tics of other interventions using naturalistic teaching strategies, but the
randomized controlled trial reporting these results was published after
the NAC (2009) synthesis. Another instantiation of the ESDM that has
been tested is to provide parent coaching in the ESDM intervention
1 hour per week for 12 weeks, without any additional professional inter-
action with toddlers with ASD. In an randomized controlled trial, the
parent-implemented ESDM did not yield significant changes in either
parent or child outcomes after 12 weeks (Rogers et al., 2012), suggest-
ing that the more intense professional involvement and longer length
of intervention in the earlier ESDM study contributed to the positive
effects.
The Early Social Interaction Project (ESI) was also designed for
children who are at risk for or have ASD, have minimal language, and
are under 3  years old. Early Social Interaction activities are embed-
ded into daily routines and, in the context of child-directed play,
adults encourage communication using behavioral strategies such
as communicative temptations and reinforcement (Dunst, Hamby,
Trivette, Raab, & Bruder, 2000; Woods, Wetherby, Kashinath, & Hol-
land, 2012). See Woods et  al., (2012) for further description of ESI.
 Children on the Autism Spectrum • 193

Significant advancement in social communication skills, as well as col-

lateral improvement in initiation and response to joint attention was
found after ESI (Wetherby  & Woods, 2006). The evidence for Natu-
ralistic Teaching Strategies that include ESI is established with some
studies providing evidence of its effectiveness when implemented by
parents (NAC, 2009; Woods et al., 2012).
At the end of infancy and into toddlerhood, typically developing chil-
dren demonstrate specific communication skills and detailed informa-
tion on this cognitive development is included in Chapter 4 of this text
(Bates, Benigni, Bretherton, Camaioni, & Volterra, 1979). Joint atten-
tion (JA) skills are among these typical communication skills and they
occur within the context of a joint engaged state where the adult and
child are focused on the same activity, object, or event during routines
(Bakeman  & Adamson, 1984). Joint attention is integral to language
development because children need to have the same joint attentional
focus as a communicative partner in order to acquire new words (Toma-
sello & Farrar, 1986). JA skills consist of protodeclaratives or gestures
used to share (e.g., pointing, showing, giving, eye contact) and absence
of these skills is a risk indicator for ASD, as well as a core deficit that dif-
ferentiates ASD from other developmental delays and disorders (Mundy
et al., 1986). For more information on JA intervention, see Kasari, Fan-
nin, and Stickles-Goods (2012).
Hwang and Hughes (2000) conducted a meta-analysis of 16 social
interactive interventions for 64 children with autism (84% boys, 2 to
12 years old, approximately 48% verbal, 21% echolalic, 31% nonverbal)
with only one study (Tiegerman & Primavera, 1984) including partici-
pants with profound social communicative delays. This meta-analysis
revealed improvements in eye contact, JA gestures, social and affective
behaviors, and nonverbal and verbal expressive language. However, few
of these gains were generalized and maintained across settings and time.
Among treatments designed to improve functional communication by
promoting early social communicative skills, however, JA treatment
has a growing body of evidence that has revealed better generalization
via RCTs.
For example, a JA RCT focused on making preschoolers with
autism (3 to 4 years old, average Developmental Quotient of 58) ini-
tiators of communication instead of the customary responders, and
the experimental JA group initiated joint engagement significantly
more often than both the ABA-only control group and a second, Sym-
bolic Play (SP) treatment group (Kasari, Freeman, & Paparella, 2006).
Furthermore, JA treatment also improved joint engagement with
maintenance of expressive language improvements in the JA and SP
194 • Fannin and Watson

groups 6 to 12 months after treatment, in contexts outside the treat-

ment room. Based on six studies of children birth to 5 years old with
AD and PDD-NOS, the NAC (2009) determined that JA interventions
are at the established level of evidence for the outcomes of interper-
sonal skills and communication.
Developmental, Relationship-Based Intervention involves an
adult interacting with the child (18 months to 9 years old) by respond-
ing to and imitating the child’s communicative attempts (Walton  &
Ingersoll, 2013). The “relationship” component of developmental,
relationship-based intervention stands for the healthy relationship
desired between the child and caregiver while the ‘developmental’ com-
ponent signifies treating the child at the appropriate developmental
level. In a comparative study of preschoolers with ASD and preschool-
ers with other behavioral and developmental disorders (N = 72), both
groups improved in language and cognitive areas as a result of a develop-
mental relationship-based intervention model (Rogers & Dillala, 1991).
Significant increases in the rate of language acquisition and decreases in
autistic symptoms for children diagnosed with PDD were also found in
Rogers and Lewis’s (1989) study.
A very salient, socially valid outcome measure is a change from an
ASD diagnosis to no ASD diagnosis. For instance, Relationship Devel-
opment Intervention (RDI), a caregiver-based treatment, was admin-
istered between 2000 and 2005 to 16 children who met ADOS/ADI-R
criteria for autism, and 100% no longer met criteria after treatment
(Gutstein, Burgess, & Montfort, 2007).
The Developmental, Individual-difference, Relationship-based
(DIR) program is another particular intervention that capitalizes on
the individual way in which each child processes information (Gerber,
2012). Greenspan and Wieder (1997), the authors of DIR, reviewed
records of 200 toddlers and preschoolers who had received a mini-
mum of 2 years of DIR, finding that 8 years posttreatment, 58% of the
participants had “good to outstanding” abilities to affectively relate to
others, engage, and participate in spontaneous verbal communication
turns (Gerber, 2012). These children also scored in the non-autistic
range on the Childhood Autism Rating Scale (CARS; Schopler et al.,
1999). Another longitudinal study of 10- to15-year-old boys with ASD
(N = 16) who had received DIR revealed significant improvement in
empathy, creativity, and reflection, along with improved academic
skills and healthy peer relationships for 58% of the sample (Wieder &
Greenspan, 2005).
Floortime is a specific treatment model within DIR, and 45.5%
of participants in a study were rated as good to very good in func-
 Children on the Autism Spectrum • 195

tional development after receiving approximately a year of treatment

(Solomon, Necheles, Ferch,  & Bruckman, 2007). Gains in JA, joint
engagement duration, communication initiation, expressive language,
vocabulary, turn-taking routines, and communication frequency
occurred when parents were more responsive as a result of the DIR/
Floortime™ training (Mahoney & Perales, 2003, 2005; McConachie, Ran-
dle, Hammal, & Le Couteur, 2005). Developmental Relationship-Based
Intervention is an emerging group of treatments for children from birth
to 5  years old with AD and PDD-NOS, resulting in increased skills
in communication, higher cognitive functions, interpersonal skills,
self-regulation, and motor skills, as well as a decrease in general symp-
toms of ASD and Sensory or Emotional Regulation (NAC, 2009).

LEAP and Other Peer-Mediated Approaches

School settings provide a natural opportunity to implement peer-mediated
interventions. Several studies have shown typically developing peers
to be realistic models of appropriate social interaction for children,
adolescents, and adults with ASD, resulting in increased academic par-
ticipation, frequency and quality of responding to others, reciprocity,
understanding others’ social communication, interacting with oth-
ers, inclusion in classroom settings, and friendship formation across
settings (Carter, Sisco,  & Chung, 2012; Garrison-Harrell, Kamps,  &
Kravitz, 1997; Walton & Ingersoll, 2013). For example, Learning Experi-
ences: An Alternative Program for Preschoolers (LEAP) is a naturalistic,
classroom-based, behavioral program where typically developing peers
model desired social behaviors in order to encourage social develop-
ment in the children with ASD. According to Odom, Boyd, Hall, and
Hume’s (2010) systematic review of comprehensive treatment models
(CTM), there is strong evidence for LEAP where, although large RCTs
are limited, LEAP is well documented, has been replicated, has evidence
of efficacy, and was the only CTM to receive the highest rating for fidel-
ity of implementation.
Based on 33 studies, peer-mediated interventions are at the estab-
lished level of evidence for the outcomes of play skills, interpersonal
skills, and communication skills for children with Autistic Disorder
and PDD-NOS, ages 3 to 14  years old (NAC, 2009). Furthermore, 15
single-case studies showed effectiveness for people with ASD, ages 3 to
18 years old, when targeting joint attention, school-readiness, academic
skills, and the aforementioned outcomes evaluated in the NAC report
(Wong et al., 2014).
Clinicians must bear in mind certain factors, however, when consid-
ering peer-mediated intervention. For instance, although peer-mediated
196 • Fannin and Watson

intervention has been implemented with children as young as 3 years

old, particular social targets may be more appropriate within certain age
ranges. Peer-initiation training, where peers initiate interactions using
techniques such as offering to share, requesting assistance, and gain-
ing the child’s attention, is most appropriate for those aged 3 through
8 years old when the goal is to help children with ASD gain social and
communication skills (Neitzel, 2008); however, training peers to form
a social “network” that supports children with ASD in their classrooms
is best for children aged 9 to 18  years old (Rotheram-Fuller, Kasari,
Chamberlain,  & Locke, 2010). Thus, despite the established status of
peer-mediated treatment, more research is needed to determine specif-
ics such as whether individual peer interactions are more effective than
group peer interactions (Cushing, Kennedy, Shukla, Davis,  & Meyer,
1997; Walton & Ingersoll, 2013).

Focused Intervention Strategies

Augmentative and Alternative Communication
Focused intervention strategies are typically individualized treatments
that include Augmentative and Alternative Communication (AAC),
Picture Exchange Communication System (PECS), social stories, and
video modeling. AAC can be used in both group and individual settings,
with graphic systems like PECS, sign language, and speech-generating
devices (SGD) being common types. These communication modalities
replace or support verbal language, augmenting the communication
of people with ASD (ASHA, 2004; Tincani, 2004). A meta-analysis of
24 case studies examined the impact of three AAC interventions (i.e.,
PECS, SGD, and non-PECS picture exchange systems) and the over-
all effect AAC had on behavior outcomes (Ganz et al., 2012). This evi-
dence confirmed that AAC had large positive effects, with the outcome
of communication being most affected among the targeted skills. All
picture based systems produced effects; however, PECS, as well as SGDs
exhibited the largest effect sizes (Ganz et al., 2012).
Researchers have offered evidence refuting the frequent assump-
tion that AAC use will hamper verbal production (Millar, 2009).
Millar, Light, and Schlosser’s (2006) meta-analysis reviewed literature
published more than 28 years that explored the effect of AAC on verbal
language for those 2 to 60 years old with intellectual disability or ASD.
There was no evidence that AAC inhibits verbal productions. Of the 23
studies, 6 had experimental controls, with 2 of those controlled studies
having participants with ASD. Charlop-Christy, Carpenter, Le, LeBanc,
and Kellet (2002) reported an increase in communicative functions for
 Children on the Autism Spectrum • 197

three children 3 to 12  years old, and Kouri’s (1988) study resulted in
significant gains for production of words with a 3-year-old with ASD.
The participants may have demonstrated ceiling effects that could have
resulted in underestimation of gains attributed to AAC, so more meth-
odologically rigorous research is needed (Millar et al., 2006).
These meta-analyses establish a broad view of the positive effect of
AAC on people with disabilities, but because there are several differ-
ent types of AAC and ASD profiles, examination of specific AAC treat-
ments for ASD is warranted, namely, (a) PECS, (b) speech-generating
devices, and (c) video modeling. Beyond the various phenotypes of peo-
ple with ASD, cultural differences must also be considered; for example,
Huer’s (2003) research described how there are cultural differences in
how people perceive several AAC symbol sets. This research provides
additional evidence that individual differences can influence effective
use of AAC. Evidence at the emerging level exists for AAC for toddlers
through adults. Specific modes of AAC that have emerging evidence
include PECS for children under 9 years of age, SGDs for children 6 to
14 years, and sign language for children ages 3 to 9 years (NAC, 2009).
The Picture Exchange Communication System is an aided, low-tech
graphic communication approach based on pictures or icons (Bondy &
Frost, 1994). It employs an applied behavior modification method of
prompting, modeling, and shaping along with a reward system to teach
functional nonverbal and verbal communication (Charlop-Christy
et  al., 2002; Frost  & Bondy, 2002). Making the most of the tendency
for people with ASD to be visual learners, clients are taught to solve
communicative problems by initiating communication or making
observations through exchange of pictures for verbal words (Schopler,
Mesibov, & Hearsey, 1995). In addition, PECS appears to decrease chal-
lenging behaviors that may occur due to the inability to express one’s self
(Frea, Arnold, & Vittimberga, 2001; Charlop-Christy et al., 2002).
Forty-one PECS studies were analyzed in two meta-analyses of AAC
(Schlosser & Wendt, 2008; Sulzer-Azaroff, Hoffman, Horton, Bondy, &
Frost, 2009). Although only Schlosser and Wendt (2008), assessed the
quality of the studies (one group design and six single subject designs),
results of both meta-analyses were consistent with the NAC’s (2009)
determination that evidence for PECS’ effectiveness is limited by nega-
tive to small gains in speech skills, small to moderate gains in commu-
nication, and low quality in generalization and maintenance (Flippin,
Rezka & Watson, 2010). In their RCT of PECS with 4- to 10-year-olds
(N  = 84, 15 schools), Howlin, Gordon, Pasco, Wade, and Charman
(2007), showed that spontaneous requests increased significantly but
spontaneous language for social purposes did not. Moreover, better
198 • Fannin and Watson

outcomes were associated with baseline characteristics such as a lower

severity rating on the ADOS. In essence, if the child had a few words
when PECS training commenced, he or she would benefit more than
one who was completely nonverbal. Additionally, the Flippin et  al.
(2010) meta-analysis revealed that Phase IV (i.e., teaching “I want . . .”
sentences), may be the section that has the most impact on speech out-
comes. Thus, when designing a treatment plan for ASD, a social com-
munication disorder at its core, clinicians must remember that evidence
is tentative for whether PECS is as useful for social communication as
it is for initiating requests, and certain phases of the intervention may
affect the outcomes differently. In their analysis of two group and four
single case design studies, Wong et al., (2014) deemed PECS effective
for 3- to 14-year-old children with ASD for social, joint attention, and
communication skills. According to the NAC (2009) analysis, evidence
for PECS is emerging because results are mixed in terms of overall effec-
tiveness.
Speech-generating devices (SGD) are portable, computerized or
battery-operated devices that substitute for or supplement verbal expres-
sion by producing digitized or synthetic speech when graphic symbols
or buttons are triggered (Wegner, 2012). Not only are SGDs effective
in enhancing expressive communication; they also have helped reduce
challenging behaviors in those with ASD (Millar, 2009). Additionally,
SGDs can be used to augment communication input (i.e., receptive lan-
guage) (Drager, 2009). For example, methods such as Natural Aided
Language, Aided Language Stimulation, and the System for Augment-
ing Language mandate that the communication partner also use the
SGD to enhance communicative input to the person with ASD, result-
ing in increased spoken words and SGD generated utterances from the
person with ASD (Cafiero, 2005; Goossens, Crain, & Elder, 1992; Rom-
ski & Sevcik, 2003).
Because SGDs are newer than manual sign or graphic systems,
there is less research on SGDs for people with ASD. There are multiple
choices in the type of device used, software, symbol selection method,
and display (Mirenda  & Erickson, 2000). Thus, in addition to inves-
tigation of whether SGDs enhance human verbal modes of treatment
delivery, studies on the most beneficial display types for development of
social and functional communication is ongoing (Wegner, 2012). The
National Standards Project (NAC, 2009) considers the evidence base for
SGDs to be emerging, as more research is needed on the best ways to
teach use of SGDs, and the best way to design devices that will have the
greatest impact on social communication, functional communication,
and language development (Wegner, 2012).
 Children on the Autism Spectrum • 199

Video Modeling Interventions

Hermelin and O’Connor (1970) declared that people with autism have
an information-processing deficit, characterized by their visuospa-
tial encoding ability being superior to their auditory processing skills
(Quill, 1997). For example, children with ASD were most successful on
IQ test tasks that involved block design, matching, form discrimination,
pattern analysis, and object assembly when the visual stimuli were con-
stantly available (DeMyer, 1975; Harris, Handleman,  & Burton, 1990;
Lincoln, Courchesne, Kilman, Elmasian,  & Allen, 1988; Siegel, Min-
shew,  & Goldstein, 1996). Thus, treatment that utilizes video is espe-
cially appropriate for people with ASD who tend to be visual learners
and those who do not readily imitate behaviors in person because of
distractors in the in vivo context (Bellini  & Akullian, 2007; Bryan  &
Gast, 2000). Hence, some people with ASD can better focus on salient
components of behaviors via video models, as the interventionist can
reduce distractions in the video context (Charlop-Christy, Le, & Free-
man, 2000).
Video modeling consists of the client seeing a video of another per-
son or themselves appropriately performing a targeted behavior (e.g.,
functional skills, social skills, language) (Bandura, 1969, 1997; Buggey,
2009). Whereas traditional video modeling shows behaviors to be imi-
tated, self observation is a video modeling variant that allows the cli-
ent to analyze what not to do (Buggey, 2012). For instance, the client
views video of an unsuccessful social interaction involving themselves,
allowing them to identify errors, devise ways to improve, and highlight
achievements. For details on video modeling implementation, see Bug-
gey (2012).
One can consider video modeling to be a combination of technology
based and modeling interventions and, although there is evidence of
its effectiveness with children of various ASD severity levels, more rig-
orous studies are necessary since most studies used multiple-baseline,
single-subject design, rendering the sample sizes small (Buggey,
2012). For instance, results of the limited number of studies targeting
school-age children have been mixed due to small samples, and almost
half the participants not responding to treatment, owing to unfamiliar-
ity with the toy used during the task or inability to attend to the vid-
eos (Nikopoulos & Keenan, 2003, 2004). In addition, studies targeting
adults and school-aged children that discern which group of people (by
severity and age) with ASD would most benefit from video modeling are
lacking (Buggey, 2012; Walton & Ingersoll, 2013). Other studies reveal-
ing negative findings included preschool participants and these results
200 • Fannin and Watson

can be explained by the notion that very young children may not have
yet developed the cognitive abilities to observe, self-reflect, judge,
remember, and apply learning to current and new contexts (Buggey,
Hoomes, Williams,  & Sherberger, 2011; Clark et  al., 1993; Lewis  &
Brooks-Gunn, 1979). Nonetheless, the majority of video modeling
research indicates that it has been appropriate for young children and
adolescents diagnosed with ASD, PDD-NOS, ASP, and autism (Bellini &
Akullian, 2007; Buggey, 2005; Delano, 2007; Dowrick, 1983; Sansosti &
Powell-Smith, 2008; Scattone, 2008). Consequently, modeling interven-
tions that include video modeling are at the established level of evidence
(NAC, 2009).

Story-Based Intervention Package

As ASD is a social communication disorder, use of story-based interven-
tion is especially appropriate for the goal of minimizing impairments
in social knowledge. Story-based intervention involves the person with
ASD writing a story that describes a particular situation and provides
key information needed for proper social responses (Gray  & Garand,
1993). The most popular story-based intervention, Social Stories, was
intended for those with ASD but has been used successfully with clients
with other intellectual deficiencies, as long as they possess basic written
and receptive language skills and understand vocabulary at their cog-
nitive level (Schneider & Goldstein, 2010). Types of sentences used in
Social Stories include Descriptive, Directive, Perspective, Affirmative,
Control, and Cooperative. For details on Social Stories sentences, see
Hutchins, (2012a), and Gray (2003).
Some efficacy studies show that Social Stories can affect indirect
outcomes including (a) better acclimation to new social situations,
(b) demonstration of appropriate behavioral routines, (c) increase
and maintenance of appropriate social behaviors for up to 10 months,
and (d) reduction in challenging behaviors (Del Valle, McEachern,  &
Chambers, 2001; Gray  & Garand, 1993; Hutchins, 2012b; Scattone,
Wilczynski, Edwards, & Rabian, 2002; Toplis & Hadwin, 2006). Limita-
tions in this evidence, however, consist of small samples with primarily
single-subject designs. Moreover, participants did not maintain social
communication gains once prompts and visual cues were removed,
and more complicated targets like securing attention required a higher
intensity of treatment to ensure mastery (Thiemann & Goldstein, 2001).
Through story-based interventions, however, the person with ASD
can increase their understanding of (a) what people are feeling, doing,
or thinking; (b) the sequence of events in a social interaction; (c) social
cues and what they mean; and (d) the script for what is customarily
 Children on the Autism Spectrum • 201

said in social interactions (Attwood, 2000; Gray, 1998, 2010; Rowe,

1999). Based on 17 single-case studies for children aged 3 to 18 years
old, story-based interventions for the outcomes of interpersonal skills
and self-regulation are at the established level of evidence for children
with AD and children with ASP ages 6 to 14 years old (Gray & Garand,
1993; NAC, 2009); but evidence for those with severe ASD is scarce
and inconclusive (Quirmbach, Lincoln, Feinberg-Gizzo, Ingersoll,  &
Andrews, 2009).
Social skills groups are a form of focused intervention where peers
(typical or with disabilities) interact in a group setting to teach interper-
sonal communication, play, or social skills. According to an analysis of
seven group-design and eight single-case studies by Wong et al. (2014),
social skills groups are effective for treating the outcomes of play, cog-
nitive skills, behavior, social skills, and communication skills for tod-
dlers to young adults with ASD. Reichow, Steiner, and Volkmar (2012)
evaluated the effects of social skills group treatment across five studies
(N = 196; ages 6–21 years), providing evidence that social skills groups
can improve quality of life based on outcomes of decreased loneliness,
improved friendship quality, and overall social competence. However,
no significant differences between the treatment and control groups
were found in understanding idioms, emotional recognition, and child/
parental depression.
Although social skills groups show promise as an evidence-based
form of peer-mediated treatment, these results cannot yet be general-
ized to a wider population, because of the lack of RCTs for social skills
groups and homogeneity of the samples characterized by exclusively
mostly 7- to 12-year-old US participants with average or above aver-
age intelligence. Furthermore, there is a dearth of evidence to support
effectiveness with adults beyond age 22. Hence, social skills groups are
at the emerging level of evidence (NAC, 2009). Although some research
is beginning to provide evidence that social skills groups can facilitate
progression of social competence skills, implementation of this type of
peer-mediated treatment in every setting, with all types of participants,
should be taken with caution owing to the lack of a robust evidence base
(Reichow, Steiner, et al., 2012).
The use of evidence-based treatment can be exemplified in the case of
Hanaa, who, approximately 5 months after the university evaluation, par-
ticipated in a 12-week research treatment program targeting joint atten-
tion and joint engagement. Mrs. A was included in sessions to facilitate
use of play routines, joint-attention, and joint-engaged states at home.
After the program, Mrs.  A  reported that Hanaa interacted and played
more appropriately with her sisters but had not yet gained many words.
202 • Fannin and Watson

At age 6, Hanaa continues to need treatment; a new SLP at the uni-

versity clinic commenced intervention approximately 2  years after
the initial evaluation and aforementioned 12-week treatment. Hanaa
exhibits many of the same sensory-seeking behaviors as earlier, mak-
ing it difficult to get her to focus. Mr. A reported that she gained new
words in English and Arabic, but Mrs. A reported that Hanaa has no
new words, despite continued treatment at her school. The university
SLP concurred with Mrs. A that Hanaa remains functionally nonver-
bal. The original evaluating SLP at the university who administered the
12-week treatment recalled that the room in which she saw Hanaa was
large with multiple distractors (e.g., cabinets to climb, a sink, electric
paper-towel dispenser, mirror wall), and recommended that treatment
be conducted in a smaller, more sterile room. The current university
SLP also requested a swing to address Hanaa’s hyposensitivity. Hanaa
may also benefit from ABA in order to learn some words, get through
daily activities at home, and learn how to use an AAC device. Using
ABA might be helpful in establishing words initially, but more joint
attention/engagement treatment would directly target Hanaa’s atten-
tion deficit and social communication. Both SLPs recommended that
an SGD be introduced, with the goals of facilitating expressive com-
munication and reducing frustration for both Hanaa and the listener.
As the evidence for ASD treatment builds and an increasing number of
more challenging participants (i.e., nonverbal, bilingual, severe ASD)
such as Hanaa are included in high-quality, controlled treatment stud-
ies, clinicians will become more efficient and precise in matching the
best, evidence-based intervention to the various phenotypes on the
autism spectrum.

DISCUSSION QUESTIONS
1. Bearing in mind the stakeholders (e.g., people with ASD and
their caregivers, health care providers, clinicians, educators),
discuss the pros and cons of the revised definition of ASD in the
DSM-5.
2. Examine the following three resources cited for ASD prevalence
in the US to identify the research designs used:
• Autism and Developmental Disabilities Monitoring. (2012).
Prevalence of autism spectrum disorders (ASDs) among multiple
areas in the United States in 2008 [PDF file].
Available from www.cdc.gov/ncbddd/autism/documents/
addm-2012-community-report.pdf.
 Children on the Autism Spectrum • 203

• Centers for Disease Control and Prevention. (2012). Preva-

lence of autism spectrum disorders—Autism and developmen-
tal disabilities. MMWR Surveillance Summary, 61(3), 1–19.
• Blumberg, S. J., Bramlett, M. D., Kogan, M. D., Schieve, L. A.,
Jones, J. R., & Lu, M. C. (2013). Changes in prevalence of
parent-reported autism spectrum disorders in school-aged US
children: 2007 to 2011–12. National Health Statistics Reports,
64, 1–12.
Describe any advantages and/or drawbacks of collecting preva-
lence data in these ways. Discuss how prevalence reports may
change based on the DSM-5 criteria for ASD.
3. Consider what additional or alternative evidence-based ap-
proaches might be implemented with Hanaa. She is currently
a functionally nonverbal, bilingual, sensory seeking 6-year-old
with severe ASD and no intellectual impairment. What addi-
tional information is needed to choose the appropriate treat-
ment? What supplemental treatment approach might fit Hanaa’s
profile? Based on the evidence presented in this chapter, what
treatments might not fit Hanaa’s profile?

CLINICAL RESOURCES
Association of Science in Autism Treatment: www.asatonline.org
• This website includes book reviews, video demonstrations of
interventions, research summaries of treatments, and the Clini-
cal Corner, where questions asked by the public are answered by
autism experts.
Autism Internet Modules: www.autisminternetmodules.org/
• This website includes evidence-based practice briefs, case stud-
ies, and video examples pertaining to 14 evidence-based ASD
interventions.
The National Professional Development Center on Autism Spectrum
Disorders: Evidence-based Practice Briefs: http://autismpdc.fpg.unc.
edu/content/briefs
• This website includes evidence-based practice briefs for ASD.
The National Professional Development Center on Autism Spectrum
Disorders (NPDCASD): http://autismpdc.fpg.unc.edu/
204 • Fannin and Watson

• This website compares the 24 NPDCASD evidence-based prac-

tices to those in the National Standards Project. It also provides
detailed descriptions of the interventions with directions for
implementation.
National Autism Center: www.nationalautismcenter.org/
• This website contains articles, information from the National
Standards Project, a Frequently Asked Question section, and
an Educator’s manual. An updated version of the NAC (2009)
report is expected to be disseminated late 2014 or in 2015.
Evaluation of Comprehensive Treatment Models for Individuals with
Autism Spectrum Disorders: http://dcautismparents.org/yahoo_site_
admin/assets/docs/ABA_14.9261728.pdf
• This is a systematic review of 30 Comprehensive Treatment
Models from the early 1970s to 2009, for people with ASD birth
to 22 years.
Evidence-based Practices in Intervention for Children and Youth with
ASD: http://autismpdc.fpg.unc.edu/content/evidence-based-practices
• This is a systematic review sponsored by the NPDC of approxi-
mately 360 Focused Intervention studies from 1997 to 2007, for
people with ASD from birth to 22 years.
Vanderbilt Evidence-Based Practice Center on behalf of Agency for
Healthcare Research and Quality: www.effectivehealthcare.ahrq.gov/
ehc/products/106/656/cer26_autism_report_04–14–2011.pdf
• This is a systematic review sponsored by AHRQ of 159 behav-
ioral, medical, educational, Allied Health, and Complementary
and Alternative Medicine studies from 2000 to 2010, for chil-
dren at-risk for ASD birth to 2 years, and children 2 to 12 years
old with ASD.
ASD Services, Final Report on Environmental Scan: www.impaqint.
com/sites/default/files/project-reports/Autism_Spectrum_Disorders.pdf
• This is a systematic review sponsored by the Centers for Medi-
care and Medicaid Services of 271 psychosocial and behav-
ioral interventions from 1998 to 2008 for children birth to
16  years, transitioning youth 17 to 21  years, and adults 21+
with ASD.
 Children on the Autism Spectrum • 205

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 8
SOCIAL COMMUNICATION ASSESSMENT AND
INTERVENTION FOR CHILDREN WITH
LANGUAGE IMPAIRMENT
Martin Fujiki and Bonnie Brinton

The social stuff is everything.

—Mother of a child with Language Impairment

LEARNING OBJECTIVES
Readers will
1. Be able to recognize the nature of social communication disor-
ders in children with language impairment (LI).
2. Be able to define social communication and describe the inte-
gration of social interaction, pragmatics, social cognition, and
language processing.
3. Be able to describe the difficulties children with LI have per-
forming various social communication tasks and the prob-
lematic social and emotional outcomes experienced by these
children.
4. Gain knowledge about methods of assessing social communica-
tion problems and a comprehensive strategy for performing the
assessment.
5. Gain knowledge regarding the efficacy of interventions designed
to improve social communication in children with LI.

220
 Children With Language Impairment • 221

CASE STUDY
As a toddler, Jennie was slow to acquire both receptive and expressive
language. She continued to have difficulty communicating, and at 4:2
(years: months) she qualified for placement in a special education
preschool program based on delays in language and pre-academic
skills. Jennie’s parents and teachers expressed additional concerns.
Jennie struggled to attend to pre-academic tasks, she sometimes
seemed anxious, and she was occasionally aggressive with peers.
At 6:0, Jennie was enrolled in a regular kindergarten classroom.
Academic tasks were very challenging for her; she had difficulty
understanding lesson content presented in class, and she struggled to
express her ideas.
Jennie’s performance on the Clinical Evaluation of Language
Fundamentals-5 (Semel, Wiig, & Secord, 2013), produced a core lan-
guage standard score of 78, consistent with her diagnosis of LI. She
received speech and language intervention on a pullout basis. In ad-
dition to her deficits in language, Jennie had difficulty with multiple
aspects of social and emotional learning. Jennxie was unable to label
basic emotions beyond happy, sad, and mad, and she struggled to un-
derstand emotion cues and to draw social inferences. Jennie was reti-
cent at school and seemed reserved and somewhat fearful interacting
with other children. For example, she often stared at other children
without interacting with them, and she sometimes stood or sat in the
midst of her peers, doing nothing when there were numerous activi-
ties going on around her. She frequently chose to play alone with toys,
sometimes building something or looking at a book by herself. At
times, however, she talked, sang, or engaged in pretend play around
her classmates without interacting with them. This behavior tended to
draw negative attention from her peers. Jennie’s teacher reported that
her sociable behavior was limited. Her teacher had never observed her
helping, sharing, or sympathizing with other children. In summary,
Jennie was at risk for academic and social problems. She existed on the
academic and social outskirts of her classroom. She presented with LI
in a traditional sense in that her receptive and expressive language abil-
ities were limited for her age. She also had difficulties with social com-
munication that undermined her relationships with her peers as well
as her participation and inclusion within her classroom community. It
seemed clear that Jennie needed intervention designed to facilitate her
language and academic development as well to support her social and
emotional learning.
222 • Fujiki and Brinton

INTRODUCTION
Early definitions of LI1 generally highlighted the syntactic and seman-
tic limitations that children with this diagnosis experience. As Jennie’s
case illustrates, however, children with LI can also experience deficits
in social interaction. Recent revisions and rethinking of diagnostic cat-
egories suggest that within the broad category of LI, there are children
who have problems with various aspects of language use that do not
stem wholly from structural limitations. At the same time, however,
these children do not meet the diagnostic criteria for autism spectrum
disorder (ASD) (Bishop & Norbury, 2002). Bishop and Norbury (2002)
labeled these children as having pragmatic language impairment (PLI).
Children with PLI may be relatively verbal but have difficulty using lan-
guage appropriately to participate in conversation, to understand what
is implied rather than actually stated in words, and to adjust language to
specific contexts. Other children identified with LI present with a more
traditional collection of symptoms, with marked deficits in the produc-
tion and comprehension of syntax, morphology, and semantics. This
refinement of the general category of LI is reflected in the organization
of the 2013 revision of the Diagnostic and Statistical Manual of Mental
Disorders (5th ed., DSM-5; American Psychiatric Association, DSM-5
Task Force, 2013), which separates language disorder from social (prag-
matic) communication disorder. These categories of impairment par-
allel Bishop and Norbury’s separation of PLI from structural LI. Even
with this separation, however, it is important to recognize that each of
these subtypes of impairment is closely associated with the other. Many
children who have trouble using language in interaction also show the
structural problems that characterize traditional LI. Likewise, many
children identified with traditional LI also have interactional concerns.
For purposes of this discussion, we consider difficulties employing lan-
guage in social situations as social communication disorders.
The actual percentage of children with LI who have social interactional
problems is difficult to determine. It is of note, however, that such difficul-
ties have been reported in these children for some time (Bishop, Chan,
Adams, Hartley, & Weir, 2000; Brinton, Fujiki, & Powell, 1997). Addition-
ally, studies that have profiled the types of linguistic difficulties experienced
by children with specific language impairment (SLI) consistently identify a
subgroup of children with pragmatic problems (e.g., Bishop & Rosebloom,
1987; Conti-Ramsden, Crutchley, & Botting, 1997). For example, Botting
and Conti-Ramsden (1999) considered results from 2 years of evaluation
of a large longitudinal sample of children placed in specialized language
units for children with SLI in England. These researchers reported that
23% (53 of 234) of the children had notable pragmatic problems.
 Children With Language Impairment • 223

Although the prevalence of pragmatic problems in these children is

important, it is perhaps just as critical to consider that many children
with LI have difficulty with a range of social communication tasks. Even
children with LI who have not been identified with specific pragmatic
issues often experience difficulty with tasks such as entering ongoing
interactions, negotiating for resources with peers, and resolving con-
flicts. As a group, these children also experience a variety of troubling
social and emotional outcomes (e.g., fewer friendships, poor peer
acceptance, higher levels of emotional difficulties).
In this chapter, we discuss the social communication problems of
children with a primary diagnosis of LI. In the literature that we con-
sider, almost all of the children have been identified with LI based on
their performance on standardized measures of language. Much of
what we write, however, will also be applicable to children who cur-
rently could be diagnosed with a social communication disorder (or
PLI) using the new DSM-5 standards. We begin by defining social com-
munication, drawing heavily on the work of Catherine Adams (2005,
2008). We particularly like Adams’s idea that successful social com-
munication requires the integration of both pragmatic and structural
language behaviors, as well as additional behaviors that reach into the
realms of social and emotional learning. We believe that treating chil-
dren with LI requires a comprehensive approach that not only addresses
their structural challenges but also considers the abilities and dispo-
sitions essential to their use of language in social interactions. At the
same time, children whose difficulties fall primarily within the realm of
social communication certainly require approaches that address their
interactional challenges.
After discussing social communication, we focus on our target popu-
lation, children with LI. We consider the social communication diffi-
culties that these children experience with an emphasis on social and
emotional learning. After describing potential problems, we present ideas
on assessment and intervention. We focus heavily on evidence-based
practice, reviewing work that has investigated the efficacy of interven-
tions with these children.

SOCIAL COMMUNICATION: WHAT ARE

WE TALKING ABOUT?
Social communication can be defined as the ability to use “language
in interpersonally appropriate ways to influence people and inter-
pret events” (Olswang, Coggins,  & Timler, 2001, p.  53). The simplic-
ity of this definition is deceptive, however. Social communication is an
224 • Fujiki and Brinton

encompassing notion that can be difficult to pin down. Defining social

communication is complicated by the tendency to equate social com-
munication with pragmatics. As Adams (2005) points out, however,
although often considered as synonymous with pragmatics, the term
social communication is more far-reaching. Successful communication
in social contexts is a complex phenomenon that includes four areas:
social interaction, language processing, pragmatics, and social cogni-
tion (as discussed in Chapters  2, 4, and 5). To review briefly each of
these areas, social interaction acknowledges the fundamental role of
early interactions between children and their caretakers in multiple
aspects of development. These interactions begin within the subjective
sharing of experience with others, or intersubjectivity. Intersubjectivity
is critical to the development of intention, which in turn is fundamental
to the acquisition of language (Westby, 2014). Although interactional
difficulties seem most pertinent for children in the earliest stages of
development, they also merit consideration in older children who have
more general developmental problems. In addition, weaknesses in the
development of basic social interactional skills may contribute to limi-
tations in the other three aspects of social communication as children
mature.
The inclusion of language processing in this framework acknowledges
the importance of the structural and lexical components of language. By
definition, children with LI have deficits in these aspects of language,
and these problems may seriously limit the ability to produce and under-
stand language. Within a social communication approach, limitations in
the syntactic and semantic aspects of language do not form the sole focus
of intervention, however. These problems are considered, monitored,
and, as necessary, addressed in holistic, authentic contexts.
Pragmatic behaviors play a key role in a social communication frame-
work. Conveying communicative intent, managing conversations, and
understanding social conventions for politeness are examples of behav-
iors that fall within the realm of pragmatics. Although it is possible
to produce a long list of such behaviors, it can be difficult to draw the
line between pragmatics and other areas of development. For example,
to engage in conversation, an individual must know how to introduce,
maintain, and change topics in conversation. To do this effectively, one
must also be able to read the social and emotional cues that a conversa-
tional partner conveys. These abilities may extend beyond the traditional
boundaries of pragmatics into Adam’s fourth area of social cognition.
The umbrella term social cognition includes a wide of range of behav-
iors. In a social communication framework, there is particular emphasis
on aspects of social and emotional learning that are critical to successful
 Children With Language Impairment • 225

communication. These abilities include understanding one’s own emo-

tions, understanding the emotions of others, and considering the perspec-
tives of others. A number of these abilities involve Theory of Mind (ToM)
and are critical to social interaction (for a review see Chapters 2 and 4).
Although social communication problems are often closely associ-
ated with autism spectrum disorders (ASD), these difficulties have been
observed in children with a range of diagnoses, including not only LI,
but also intellectual disability, hearing impairment, and learning dis-
ability (e.g., Brown, Odom, & McConnell, 2008). As noted previously,
although social communication and structural language problems often
co-occur within the broader category of LI, it is also possible for social
communication problems to occur without being linked to structural
impairments.

THE SOCIAL COMMUNICATION SKILLS

OF CHILDREN WITH LI
Jennie presented with LI that was manifested in her language compre-
hension and production as well as in other aspects of social communi-
cation. Research suggests that like Jennie, many children with LI have
difficulty with a range of important social communication abilities. We
review a sampling of this research in the following sections.

Important Social Tasks and LI

Entering the Interaction
Joining an on-going interaction can be difficult for anyone, and stud-
ies have shown that it is particularly challenging for children with LI
(Brinton, Fujiki, Spencer, & Robinson, 1997; Craig & Washington, 1993;
Liiva & Cleave, 2005). To illustrate, Craig and Washington (1993) intro-
duced two previously unacquainted children. Once these children were
engaged in cooperative play, a target child was introduced to them. Chil-
dren with LI and typically developing peers served as target children.
All of the typical target children successfully entered the on-going play.
Three of the five target children with LI did not enter the interaction
during a 20-minute period (similar results were reported by Brinton,
Fujiki, Spencer, et al., 1997, and Liiva & Cleave, 2005).

Integrating One’s Self Into Group Interaction

In each of the three studies cited earlier, some children with LI were able
to enter the on-going interaction, although most did not do it quickly.
226 • Fujiki and Brinton

It might be hypothesized that if a child with LI had the skills to enter

the interaction, he or she would also have the skills to become an active
participant. Brinton, Fujiki, Spencer, et al. (1997) and Liiva and Cleave
(2005) both considered this possibility by examining children who were
able to join the group. In both studies, after children with LI joined the
other children, they were often marginalized in the subsequent group
interaction. The triad frequently became a dyad, with the two typical
children interacting with each other to the exclusion of the child with
LI. These findings parallel observations made by other researchers who
have observed group interactions involving children with LI (Grove,
Conti-Ramsden, & Donlan, 1993; Guralnick, Connor, Hammond, Gott-
man, & Kinnish, 1996).

Negotiating for Resources

Children must often negotiate with their peers for resources. This
skill is particularly important in the school context where materi-
als, food, and even friends must sometimes be shared. As might be
expected, children with LI have difficulty with negotiation tasks (Brin-
ton, Fujiki, & McKee, 1998; Grove et al., 1993). For example, Brinton
and colleagues observed triadic interactions, in which a child with LI
interacted with two peers to select a treat to be shared by all three
children. Children with LI used less sophisticated negotiating strate-
gies (e.g., ordering a peer to perform an action, or disagreeing with
a peer’s statement without offering a reason for disagreeing) than did
typical peers, and they frequently were excluded from the final deci-
sion. Although limitations in syntax, vocabulary, and aspects of verbal
ability may have played a role, these difficulties could not completely
explain the differences observed.

Resolving Disputes
Childhood is filled with conflicts with peers, and children need to learn
how to resolve these disputes in positive ways that preserve relationships.
To study conflict resolution, researchers have frequently presented chil-
dren with hypothetical scenarios and asked what strategies they would
use to resolve a potential disagreement (e.g., another child will not share
materials needed to complete a school assignment; e.g., Erdley & Asher,
1999). Several researchers have used this methodology with children
with LI (e.g., Marton, Abramoff,  & Rosenzweig, 2005; Timler, 2008).
In these studies, children with LI often produced less effective strate-
gies to resolve conflicts. For example, Timler (2008) found that children
with LI did not differ from typical peers in the number of strategies
produced, but they produced fewer prosocial strategies. Thus, children
 Children With Language Impairment • 227

with LI were less likely than typical children to make a polite request or
to suggest a strategy that would meet the needs of both children, such as
“Let’s flip a coin” (Timler, 2008, p. 750).
Horowitz, Jamsson, Ljungberg, and Hedenbro (2005) used a more
direct (and more laborious) methodology to examine conflict resolu-
tion. These researchers observed naturally occurring conflicts in pre-
school age boys. Typical boys interacted with other typical boys, and
boys with LI interacted with other boys with LI. The typical boys
resolved a significantly greater number of conflicts than did the boys
with LI. As might be expected, boys with poor language skills were less
able to resolve conflicts verbally, and they did not compensate using
nonverbal means. Interestingly, boys with LI were involved in more
conflicts that the researchers labeled as “aberrant” (p.  440). That is, a
child’s behavior intensified to the point of driving the other child away
(e.g., friendly wrestling became too rough and the other child withdrew
from the play).

Learning in Cooperative Group Activities

Cooperative learning tasks in which several children work together
on a project are widely used in school settings. Although cooperative
learning models can be highly beneficial, children with LI may not
do well in these groups without extra support. For example, Brinton,
Fujiki, and Higbee (1998) examined the verbal and nonverbal behav-
iors produced by children with LI and their typically developing peers
in cooperative work settings. Typical children matched for age and lan-
guage level were also examined. The triads of typical children gener-
ally worked collaboratively, resulting in a balanced interaction among
the children. The triads with a child with LI (and two typical peers)
frequently turned into dyads, with the exclusion of the child with LI.
Interestingly, children with LI did not compensate for their language
limitations by using nonverbal behaviors. Rather, they contributed
fewer nonverbal cooperative behaviors than did the typical children.
Brinton, Fujiki, Montague, and Hanton (2000) also observed children
with LI interacting in a cooperative work project with two typically
developing peers. For children with LI, successful interaction was more
influenced by the sociable behaviors of the child (e.g., helping or com-
forting others, controlling one’s temper, sharing materials) than by the
child’s language level.
In summary, it is likely that the inability to take part successfully in
peer interactions could contribute in social and emotional difficulties.
This turns out to be the case, as illustrated by the sampling of research
reviewed in the next section.
228 • Fujiki and Brinton

Problematic Social and Emotional Outcomes

There is considerable evidence that children with LI often experience
problematic social outcomes. Children with LI as young as 2 years of age
scored lower on measures of socialization when compared with typi-
cally developing peers (e.g., Paul, Looney,  & Dahm, 1991). Preschool
children with poor speech and language skills were perceived by peers
as less desirable playmates in sociodramatic play than were children
with typical language skills (Gertner, Rice, & Hadley, 1994).
Elementary school-age children with LI consistently demonstrate
higher rates of social difficulty than do their typical peers. These chil-
dren have fewer friends and are less well accepted by peers (Fujiki, Brin-
ton, Hart, & Fitzgerald, 1999). Additionally, teachers rate children with
LI as having poorer social skills, more problem behaviors, and higher
rates of reticent withdrawal than typical children had (Fujiki, Brinton,
Morgan, & Hart, 1999; Fujiki, Brinton, & Todd, 1996). Conti-Ramsden
and Botting (2004) found high rates of social difficulty in a longitudinal
sample of children with LI. These children also reported experiencing
higher rates of victimization (bullying) than did typical peers. Lindsay,
Dockrell, and Mackie (2008) also found high rates of bullying based on
self-ratings, but levels were not significantly different than those expe-
rienced by typical children (54% in the group with LI compared to 46%
in the typical children).
Adolescents with LI continue to experience a variety of social diffi-
culties. Tomblin (2008) examined data from a large longitudinal sample
(children studied from ages 7 to 16  years). At age 16, these individu-
als had fewer social contacts. Individuals with LI had a higher rate of
emotional difficulties (e.g., depression), but these problems were linked
to IQ level. The adolescents with LI also had a higher rate of rule break-
ing than did their typical peers, but this did not extend to more seri-
ous criminal behavior. It was of note that the 16-year-olds with LI rated
themselves as lower on global self-esteem, but their ratings of satisfac-
tion with life did not differ from those of their typical peers. As Tom-
blin pointed out, these positive ratings may have been tied to the fact
that quality of life at age 16 is heavily influenced by the parents (living
arrangement, income, etc.).
Conti-Ramsden and her colleagues at the University of Manchester
also followed a large group of children with LI. From ages 7 to 16 years,
individuals with LI experienced increasing difficulty interacting with
peers (St.  Clair, Pickles, Durkin,  & Conti-Ramsden, 2011). When
sampled at 16  years of age, these adolescents reported fewer friends
(Durkin & Conti-Ramsden, 2007) and fewer close relationships (Wad-
man, Durkin, & Conti-Ramsden, 2011) than did typical peers.
 Children With Language Impairment • 229

Beitchman and colleagues followed a large group of Canadian chil-

dren with speech and language problems from age 5 to adulthood
(Brownlie et  al., 2004). Although levels of socio-emotional difficulty
were consistently higher in this group than for typical individuals, these
rates decreased somewhat between ages 19 and 25 (Vida et al., 2009).
At age 25, these young adults with LI had poorer outcomes in several
aspects of life, including educational and occupational status. Their per-
ceptions of quality of life did not differ from typical individuals, but
these positive perceptions were closely linked to levels of social sup-
port provided by family, friends, and other social contacts. Additionally,
the number of individuals who were married or had a partner did not
significantly differ between groups (Johnson, Beitchman,  & Brownlie,
2010). This finding contrasted with other studies reporting poorer out-
comes regarding romantic relationships for adults with LI (e.g., Clegg,
Hollis, Mawhood, & Rutter, 2005).

FACTORS INFLUENCING SOCIAL OUTCOMES

FOR CHILDREN WITH LI
There is little doubt that LI has an impact on social relationships. There
are indications, however, that additional factors also play a role in the
social outcomes experienced by children with LI. For one thing, if lan-
guage deficits alone accounted for poor social outcomes, we would
expect almost all children with LI to experience such difficulties. In fact,
some do well socially. Durkin and Conti-Ramsden (2007) found that
92% of typical 14-year-olds reported a normal range of social relation-
ships, compared to 54% of individuals with LI. Although these differ-
ences are striking, still a sizable group of persons with LI reported a
typical social experience.
If LI alone dictated social outcomes, it might also be expected that
children with the most severe language problems would also have the
most serious social difficulties. Hart, Fujiki, Brinton, and Hart (2004)
considered this question by looking at the relationship between lan-
guage and two general domains of social behavior—sociability and
withdrawal. These researchers found that severity of LI was linked to
problematic sociable behavior. Children with less impaired language
generally demonstrated higher levels of both prosocial and likeable
behaviors than did children with more impaired language. In contrast,
there was little connection between various subtypes of withdrawn
behavior (e.g., reticent withdrawal, solitary passive withdrawal) and
language level. This finding suggests that social behaviors that require
230 • Fujiki and Brinton

children to extend themselves (offering comfort, sharing, etc.) are more

influenced by language skills than behaviors that do not.
It is likely that a number of variables influence social outcomes in
children with LI. Some of these factors are probably internal (e.g.,
nature and severity of the language difficulties, temperament) and
others external (e.g., availability and nature of educational programs,
social support from family and friends). One developmental domain
that has received relatively little attention in the study of LI is emo-
tional intelligence. Given the strong connection between social and
emotional competence (Thompson, 2011), however, a case can be
made that emotional development merits consideration. Further, there
are indications that aspects of emotional intelligence, particularly
those related to ToM, may play a key role in the social interactions of
children with LI.

Emotional Intelligence and Children With LI

A number of studies have suggested that there is a connection between
aspects of emotional intelligence and the social competence of chil-
dren with LI. For example, Fujiki, Spackman, Brinton, and Hall (2004)
used a regression analysis to show that emotion regulation and lan-
guage predicted 43% of the variability in social reticence scores in
elementary school-age children with LI. Other work has indicated that
some children with language problems experience difficulty with addi-
tional aspects of emotional intelligence, particularly the ability to rec-
ognize and understand the emotions of other people. These difficulties
involve basic recognition of emotion expressed on faces as well as in
voices (Boucher, Lewis, & Collis, 2000; Courtright & Courtright, 1983;
Fujiki, Spackman, Brinton,  & Illig, 2008; Spackman, Fujiki, Brinton,
Nelson,  & Allen, 2006). Illustrative of this work, Fujiki et  al. (2008)
presented a seven-sentence passage to elementary school-age children
and their typically developing peers. The passages were constructed to
minimize the syntactic and semantic demands of the task. The same
passage was again read by actors using prosody to express happiness
fear, anger, and sadness. The children with LI had significantly more
difficulty than did typically developing peers identifying the emotion
being expressed.
Children with LI also have difficulty with more complex emotion
understanding tasks, such as inferring emotional reactions of others
(Ford & Milosky, 2003; Spackman, Fujiki, & Brinton, 2006) and under-
standing when to hide an emotional reaction for social purposes (Brin-
ton, Spackman, Fujiki, & Ricks, 2007). For example, Ford and Milosky
(2003) asked kindergarteners with LI and typical peers to infer the
 Children With Language Impairment • 231

emotion that a character named Twinky would experience, given a basic

scenario (e.g., “Twinky wanted a teddy bear for his/her birthday. S/he
opened a present with a big fluffy teddy bear. Twinky was _____”; p. 24).
The emotions of happy, sad, mad, and surprised were tested. Children
with LI had significantly more difficulty making emotional inferences.
In fact, the children with LI were not only less accurate at inferring what
emotions Twinky would experience; they also made more valence errors,
confusing positive and negative emotions. Spackman, Fujiki, and Brin-
ton (2006) replicated these results with older elementary children with
LI. Although these children did not make many valence errors, they still
performed significantly more poorly than did their typical peers.

Summary
Children with LI have difficulty with a range of social tasks, includ-
ing entering ongoing interactions, negotiating with peers, and resolv-
ing disputes. It follows that they would also experience a number of
poor social outcomes, including poor peer acceptance and higher rates
of social and emotional problems. In considering why these children
experience social difficulties, one might consider linguistic deficits as an
obvious explanation. There are indications, however, that LI alone does
not explain all of the variance seen in these children. Aspects of social
cognition such as emotion understanding also play an important role.

ASSESSMENT OF SOCIAL COMMUNICATION

Assessment of social communication can be conceptualized as a ques-
tioning process. That is, we formulate several questions, and proceed to
address those questions by employing various diagnostic procedures.
Traditionally, we have formulated our questions focusing primarily on
the individual suspected of having a problem. In a social communication
approach, it is important to extend those questions to include the per-
sons who have a stake in that individual’s welfare. In the following sec-
tion, we discuss the influence of stakeholders and the important contexts
in which the child interacts with others. We then review questions we
might pose in evaluating the various aspects of social communication.

Stakeholders
• Who are the stakeholders concerned in the child’s development?
• What are the priorities of these stakeholders?
• What are the family and cultural considerations that have an
impact on the child’s communication?
232 • Fujiki and Brinton

• Who are the persons within the child’s social circles?

• What are the important contexts in which the child interacts
with persons in the social circles?
• How well does the child interact within these contexts?
Stakeholders are the prominent people in the child’s life. Stakeholders
include the child’s family members, teachers, special service providers,
and others who have an interest in the child’s welfare. For most chil-
dren, parents (or caretakers), followed by other family members, will be
most important. In recent years there has been a great deal of attention
focused on the importance of considering a family’s cultural perspective
in both assessment and intervention. This focus is critically important
in assessing social communication. Interactional behaviors are heavily
influenced by cultural norms and expectations. For example, parents’
beliefs about communicating with their children (how much a parent
talks to the child, when and where they talk, what they talk about, etc.)
are often dictated by cultural standards (Goldstein  & Horton-Ikard,
2010). In order to understand the interactional behaviors that are
observed, it is necessary to understand what is considered appropriate
within a particular culture.
A second reason for considering the cultural perspective of the fam-
ily is that the cultural biases and stereotypes clinicians bring to the
assessment process can influence clinical outcomes. This concern is not
limited to speech-language pathology services. For example, there is
considerable evidence that quality of medical treatment can be nega-
tively influenced by the cultural biases of service providers (Smedley,
Stith, & Nelson, 2003). It is important to consider how one’s own cul-
tural views line up with those of the family. This is fundamental when
working with persons from different racial, linguistic, and ethnic back-
grounds. It may also be an issue in cases where cultural differences are
more subtle, however.

Important Communicative Partners and Communication Contexts

Understanding the perspectives of stakeholders can help in identify-
ing important communicative partners and contexts. It is important
to consider both the interactional partners with whom the child talks
as well as the contexts in which those interactions occur. One way to
gather this information is through interviewing caretakers and other
important stakeholders. If appropriate, the clinician will also want to
interview the child directly. A successful interview will require develop-
ing both trust and rapport with the individual and family. Ethnographic
interviewing is a strategy that may be helpful in accomplishing both of
 Children With Language Impairment • 233

these goals (Westby, Burda, & Mehta, 2003). This procedure involves a

series of open-ended questions asked within a two-way interaction.
Blackstone and Hunt Berg’s (2003) social network analysis is a use-
ful way of organizing information regarding important communicative
partners and contexts. The child’s potential conversational partners are
organized into social circles. The innermost circle consists of family
members. Moving outward, subsequent circles include close friends,
acquaintances, and finally those who are paid to interact with the indi-
vidual (teachers, SLPs, etc.). This system was developed for persons with
complex communication needs (including users of augmentative and
alternative communication [AAC]), but it can provide useful informa-
tion for individuals with a range of communication abilities. The exam-
iner can supplement the social network analysis with information such
as whom the child talks to the most, the contexts in which the child
interacts, and the topics the child enjoys talking about. It may be the
case that a child has many conversational partners, but most of them are
paid or in some way obligated to interact (e.g., the classroom teacher,
soccer coach, Sunday school teacher).

Assessing Components of Social Communication

Assessment of the child’s general development provides an important
backdrop for the evaluation. Our specific focus, however, is on the major
aspects of social communication. As noted, the first component, social
interaction, is particularly relevant for children in the earliest stages of
language acquisition. For older children, the primary focus will usually
be on language processing, pragmatics, and social cognition (Adams,
Lockton, Gaile, Gillian,  & Freed, 2012). A  comprehensive review of
methods and procedures that assess these abilities is beyond the scope
of this chapter. Although we mention some specific procedures, we
focus on the general questions to address in assessment. We suggest
examples in the following section, but both the questions posed and the
procedures employed to address these questions should be geared to the
needs of individual children.

Language Processing
• Does the child have the expressive and receptive vocabulary to
express personal experience, convey information, understand
and tell stories, and participate in academic learning tasks and
units?
• Does the child understand and produce the sentence structure
needed to share experience and describe cause-and-effect rela-
tionships?
234 • Fujiki and Brinton

• Does the child have the expressive and receptive vocabulary to

label, describe, express, and understand emotion?
Assessment of language processing largely involves considering the
structural and semantic aspects of language production and compre-
hension. Deficits in these aspects of language are common in chil-
dren with LI and may play a role in the limitations of children with
related diagnoses such as PLI. Speech language pathologists and others
who work with children with LI are highly familiar with both stand-
ardized tests and informal assessment tools that can be used to assess
these problems. From a social communication perspective, however, it
is important to go beyond documenting deficits in expressive and/or
receptive language abilities. Rather, emphasis is placed on determining
how children’s strengths and limitations in language processing contrib-
ute to their interactions with others in a variety of educational and social
contexts. Accordingly, we want to know how the child’s language pro-
cessing abilities support sharing personal experiences and comprehen-
sion of story structures and literature. In addition, it is also important
to assess how the child’s language processing facilitates participation in
classroom learning activities. We pay particular attention to the vocabu-
lary and structures that allow children to understand and convey emo-
tion. This involves emotion words (especially those that go beyond the
basic emotions, “happy, mad, sad”) as well as complex sentence struc-
tures used to link emotions with the sources that elicit them (e.g., If
Tommy sees the dragon, then he will be scared).
Pragmatics
• Can the child express a variety of communicative intents?
• Does the child take turns in conversation appropriately?
• Does the child manipulate topic in conversation appropriately?
• Is the child responsive to questions and requests for repair?
• Can the child request repair when needed?
• Does the child recognize and adjust conversational contribu-
tions according to accepted standards of politeness?
The assessment of pragmatics can include a range of behaviors, begin-
ning in the early stages of language development with a focus on com-
municating intention. Most children with LI can express a variety of
intents, but they may do so with limited words and structures. When
addressing questions about pragmatics, it is important to focus on con-
versational behaviors that represent moments of cooperation between
speaker and listener. For example, does the child exchange turns appro-
priately? Can the child initiate and maintain topics, and is the child
 Children With Language Impairment • 235

responsive to topics introduced by other speakers? Does the child

respond to requests for conversational repair (e.g., “What?” “A  blue
one?”), and can the child request repair when needed? (Requesting
repair depends on comprehension monitoring which may be problem-
atic for children with LI.)
Although there are standardized assessments that consider prag-
matic behaviors, there are notable limitations to examining pragmatics
in highly standardized contexts. A good place to start the assessment of
pragmatic behaviors is by observing the child in social conversations.
These direct observations may be supplemented by the impressions of
individuals who know the child well (e.g., teacher, parent). Measures
that use a rating scale or report form format such as the Children’s Com-
munication Checklist, second edition (Bishop, 2003) or the Language
Use Inventory (O’Neill, 2007), can provide a useful way of organizing
the impressions of stakeholders. These types of instruments have several
advantages. Rating scales take advantage of the observations of people
who have known the child over extended periods. They are relatively
efficient to use and can provide information about important but infre-
quently occurring behaviors. On the negative side, these scales sample
impressions of behaviors, not actual behaviors. Additionally, they can be
influenced by the biases of the rater (e.g., too lenient or too stringent).
Rating scales may also be subject to variability related to specific set-
tings, times, and other factors that might skew the impressions of the
rater (Merrell, 2003). The fact remains, however, that when used with
care and recognition of potential limitations, these types of measures
can provide highly useful information.
As helpful as rating scales are, it is important to analyze how a child
actually performs in conversation. Various methods of conversational
analysis have the potential to provide a description of a child’s interac-
tional behavior (e.g., Brinton & Fujiki, 1989). These procedures can be
very time consuming, however. Some researchers have developed meth-
odologies for online analyses of interactional behaviors (e.g., Olswang,
Coggins, & Svensson, 2007), making these detailed analyses more feasi-
ble in clinical situations.
In addition to the analysis of natural conversation, the clinician may
also want to examine specific abilities using tasks designed to elicit these
behaviors. There are numerous examples of these tasks in the literature.
For example, we used a topic task to probe the abilities of children with
LI to maintain a topic introduced by a conversational partner (Brin-
ton, Fujiki, & Powell, 1997). In this task, the examiner introduced some
topics in association with an object (e.g., “My brother wants me to wear
these. I  don’t know about that,” spoken while placing an odd pair of
236 • Fujiki and Brinton

sunglasses on the table). Other topics were introduced verbally only

(e.g., “I walked to school this morning. I saw a dog. It almost bit me”;
examples from Brinton, Fujiki, & Powell, 1997, p. 5). All of the children
were able to maintain some topics, but children with LI produced far
more utterances that did not maintain the topic than did typical peers.
As another example, we performed a number of studies in which we
inserted stacked sequences of requests for repair (e.g., “Huh? What?
What?) to probe children’s ability to adjust their input to accommodate
listeners (Brinton, Fujiki, & Sonnenberg, 1988). Children with LI tend
to be limited in the sophistication of their responses (e.g., repeating their
original repair rather than adjusting it in response to the listener’s diffi-
culty, or responding off topic as the sequence progressed). Tasks such as
these may be inserted into natural interactions to probe specific aspects
of conversational behavior.

Social Cognition
• Does the child regulate emotion appropriately?
• Does the child recognize facial expressions of emotion?
• Can the child label/express experienced emotion appropriately?
• Can the child infer what others might be thinking in a specific
scenario?
• Can the child infer what others might be feeling in a specific
scenario?
• Does the child understand that others may experience emotions
different from his or her own in a given situation?
• Can the child infer the social motivations of characters in sto-
ries?
• Can the child anticipate the emotions his or her actions might
elicit?
As noted, social cognition is an umbrella term that encompasses a wide
range of abilities and behaviors. We focus on several aspects of social
and emotional learning that are (a) important to social interaction and
academic success and (b) have been shown to be at risk for children
with LI. For example, it is helpful to consider how well children with
LI regulate emotion. Two aspects of emotion regulation, calming down
and gearing up, affect a child’s motivation and availability to learn.
We are concerned with how well children calm themselves when they
are experiencing intense emotion, and we are just as concerned with
how children are able to gear themselves up to enter interactions or
accomplish difficult tasks. Observation and caregiver and teacher report
can be useful in determining how well children regulate emotion in
 Children With Language Impairment • 237

various contexts.
It can be helpful to probe several types of emotion knowledge that
play important roles in social communication. Although children
begin to learn to interpret facial expressions of emotion in infancy, this
remains a difficult task for some children with LI. Various tasks (some
standardized) can be employed to determine how well children inter-
pret emotion in still pictures (e.g., Ekman, 2014) and videos (e.g., Brin-
ton, Robinson, & Fujiki, 2004). It is also helpful to probe how children
express emotion. Specifically, do they have the vocabulary to label emo-
tion and do they understand the emotion display rules of their commu-
nity? It is also helpful to explore ToM tasks. Current conceptualizations
of ToM consider both a more traditionally recognized “cognitive” ToM
(e.g., used to complete a false belief task) and an “emotional” ToM (see
Westby, Chapter 2 of this volume). This affective ToM has to do with
understanding the emotional perspectives of others and recognizing
that those perspectives may differ from one’s own, even in identical situ-
ations. It can be useful to examine how well children infer the emotion
a person might experience in a basic scenario (e.g., see task used by
Ford & Milosky, 2003). This task provides information about how well
children link sources (e.g., events, scenarios) with the emotions they are
likely to elicit in individuals with various backgrounds and dispositions.
The ability to make these kinds of social inferences will underpin chil-
dren’s comprehension of stories and literature.
Some children with LI have difficulties interacting because they can-
not predict the emotions that their own actions might elicit in others.
This difficulty may well be tied to problems recognizing the emotion
cues that others convey. It may be possible to help children with LI
reflect on the emotional reactions of those with whom they interact.

Summary
In this section we posed several questions that, when geared to the needs
of an individual child such as Jennie, may guide assessment. It is impor-
tant to begin with the stakeholders and the culture within which the
child communicates. In Jennie’s case, it was important to obtain infor-
mation from her mother and her teacher regarding her general devel-
opmental history and her current social communication needs at home
and in the classroom. We were then prepared to employ formal test-
ing, teacher/parent report measures, observation, and specific tasks to
probe the four components of Jennie’s social communication. Standard-
ized testing measures documented impairment in both expressive and
receptive language processing. Teacher interviews highlighted Jennie’s
difficulty with academic work, particularly story comprehension and
238 • Fujiki and Brinton

literacy tasks. Teacher report measures also suggested difficulties with

both social cognition and pragmatics manifest in reticent behavior, lim-
ited prosocial skills, and a lack of responsiveness to peers. A series of
probes of social and emotional learning, particularly emotion under-
standing, revealed that Jennie did not easily recognize facial expression
of emotion. She often did not label emotions accurately, and she had
difficulty predicting what emotion an event might elicit. Jennie pre-
sented with language impairment in the traditional sense, but she also
demonstrated associated difficulties with social cognition and pragmat-
ics. By synthesizing and integrating information obtained from multiple
sources, we were able to get a sense of Jennie’s functioning in the con-
texts that were important in her social world.

SOCIAL COMMUNICATION INTERVENTION

In the following section, we begin by considering work to improve the
social and emotional learning of typically developing children. We then
review research focusing on interventions to improve social communi-
cation skills in children with LI.

Social and Emotional Learning Programs for

Typically Developing Children
Social communication depends heavily on social and emotional learn-
ing. Social and emotional learning refers to the processes by which chil-
dren learn to “understand and manage emotions, set and achieve positive
goals, feel and show empathy for others, establish and maintain positive
relationships, and make responsible decisions” (Collaborative for Aca-
demics, Social, and Emotional Learning [CASEL] Guide, 2012, p. 4). In
recent years, there has been a good deal of work devoted to designing
and implementing educational programs to facilitate social and emo-
tional learning in school settings. To date, there is strong evidence that
when these programs are implemented in a comprehensive, rigorous
manner, they are highly successful. For example, Durlak, Weissberg,
Dymnicki, Taylor, and Schellinger (2011) reported a meta-analysis of
213 studies involving 270,034 students. Results indicated that children
and adolescents who participated in educational programs targeting
social and emotional learning had significantly better outcomes than
controls on assessments of emotional problems, behavioral disorders,
social skills, and emotional competence. Significant differences were
not limited to social and emotional domains, however, but were also
observed in measures of academic performance including grades and
achievement test scores.
 Children With Language Impairment • 239

Social Communication Interventions for Children

With Language Deficits
The evidence for social communication intervention programs for
children with disabilities is mixed. In addition, there are relatively few
studies investigating interventions designed to facilitate social and
emotional competence specifically in children with LI (Gerber, Brice,
Capone, Fujiki, & Timler, 2012). There have been a number of investi-
gations, however, examining aspects of social functioning in a similar
(overlapping) population. For example, studies have examined social
skill training interventions for children with learning disabilities (LD).
Kavale and Mostert (2004) conducted a meta-analysis of 53 studies
examining social skill interventions for children with LD and found
modest effects. Kavale and Mostert suggest that a number of factors
may be responsible for this outcome, including the use of interven-
tion packages that lack a fundamental rationale for how procedures
are combined and applied, the lack of sufficient intensity of training,
and the difficulty in conceptualizing and then measuring variables of
interest. In the following section, we review a few of the studies report-
ing successful outcomes for children with LI. Although our discus-
sion is not comprehensive, the studies discussed are representative of
this work.

Randomized Controlled Trial for Social Communication Skills

Adams and colleagues (Adams, Lockton, Freed, et  al., 2012; Adams,
Lockton, Gaile, et  al., 2012) have conducted the only randomized
control trial (to date) to facilitate social communication skills in chil-
dren with LI (specifically focusing on PLI). Adams and her colleagues
administered a comprehensive intervention program to a group of 57
children with pragmatic problems. Outcomes were then compared with
a group of 28 children who received treatment as usual. The interven-
tion addressed multiple areas of social communication, including ToM,
social inferencing, and conversational ability. Specific intervention tar-
gets were geared to the problems experienced by individual children,
however. Children in the treatment group did not produce greater
gains than the control group in structural language and narrative lan-
guage abilities as measured by the Clinical Evaluation of Language
Fundamentals–4 (Semel, Wiig, & Secord, 2006). Positive improvement
was noted in blind ratings of quality of conversation, however. Addi-
tionally, parent and teacher ratings of pragmatic ability also improved
in comparison to controls (see Adams, Chapter 6 in this volume). The
intervention represented a well-thought-out, comprehensive treatment
package that was adjusted to meet the needs of specific students. The
240 • Fujiki and Brinton

individualized nature of this program was relatively unique and likely

contributed to positive outcomes.

Single-Subject Research Involving Children With LI

Although the Adams randomized control trial is arguably the most
notable group intervention study available, there is much to learn from
research using other methods, particularly well-designed single-subject
research. Because there is notable heterogeneity among children with
LI, single-subject design studies evaluating specific interventions can
show how individuals with unique strengths and limitations respond
to treatment.
Single-subject designs have been used to target a variety of social
communication behaviors in children with LI (e.g., Craig-Unkefer  &
Kaiser, 2002; Goldstein, Wickstrom, Hoyson, Jamieson, & Odom, 1988;
Stanton-Chapman, Denning,  & Roorbach Jamison, 2012; Stanton-
Chapman, Kaiser, Vijay,  & Chapman, 2008). It should be noted that
some of these studies included children presenting with a variety of defi-
cits, most frequently involving a combination of language and behavio-
ral problems (although children with diagnoses of intellectual disability
or ASD were excluded). The researchers in many of these studies used
a similar intervention format. The children received instruction and
then were provided with an opportunity to practice skills. The practice
(often integrated into a procedure such as script training or sociodra-
matic play) was followed by an opportunity to review performance. For
example, Stanton-Chapman and colleagues have conducted a number
of studies employing such procedures. In one of the more recent stud-
ies, Stanton-Chapman et al. (2012) followed eight preschoolers at risk
for social, behavior, and language problems. The children were seen for
intervention in dyads. Treatment began with a 10-minute segment in
which the children were instructed as to the possible roles they would
assume during a sociodramatic play scenario (e.g., grocery store, doc-
tor’s office). The clinician then read a story focusing on the scenario.
During the story, instruction was provided targeting specific social
communication strategies (initiating, responding, using the person’s
name, and turn taking). These strategies were introduced one at a time
over the course of the first 12 sessions. After listening to the story, chil-
dren selected their roles and received additional instruction as to how
the targeted strategy might be used. Instruction time was also devoted
to teaching the vocabulary needed to execute the play scenario.
The actual play session made up the second component of the inter-
vention (also 10 minutes long). The clinician helped the children to
 Children With Language Impairment • 241

select appropriate costumes and the other items needed to act out the
roles. The children then acted out the play scenario. The clinician was
not directly involved in the play, but provided prompts for the children
to use the targeted strategies as well as appropriate vocabulary words.
Prompts were delivered according to predetermined rates and condi-
tions (e.g., if a child did not engage in a targeted behavior after the first
minute, the clinician provided a prompt). The play session was then fol-
lowed by a 5-minute review session. The clinician first reviewed the role
played by the children. Next, targeted vocabulary items were presented
followed by specific social communication strategies. The intervention
produced increases over baseline levels of production of both positive
verbal initiations and appropriate responding to the bids of peers.

Additional Studies of Social Communication Abilities

Case Study Designs
Additional studies describing social communication interventions for
children with LI are available. Many, but not all of these investigations use
case study or multiple case study designs and are exploratory in nature.
Interventions have focused on behaviors such as increasing conversa-
tional responsiveness (Brinton et al., 2004), facilitating the production
of positive comments (Fujiki, Brinton, McCleave, Anderson, & Cham-
berlain, 2013), and enhancing pragmatic and social cognitive behaviors
(Adams, Lloyd Aldred, & Baxendale, 2006). These studies have employed
a variety of methods, including the instruction–practice–review proce-
dures described previously. Although the outcomes of these case studies
have been promising, they also highlight the persistence of social com-
munication problems in individual children as well as the challenge of
monitoring change in authentic interactional contexts.

Group Designs
A number of authors have studied interventions designed for larger groups
of children with LI. For example, Schuele, Rice, and Wilcox (1995) con-
ducted an intervention within a classroom context. Specifically, Schuele
and colleagues examined the impact of redirecting child initiations from
adults to peers. This strategy, implemented by the classroom teacher, pro-
duced an increase in peer initiations in the four children studied.
Richardson and Klecan-Aker (2000) performed a treatment study
focusing on aspects of social communication in a group of children
with language learning impairment. The children, who were placed in
two self-contained classrooms, were formally diagnosed with LD, but
242 • Fujiki and Brinton

language deficits were documented through a standardized, global lan-

guage test. Intervention focused on facilitating conversational skills
and object description as well as receptive identification and expressive
labeling of facial expressions of emotion. Improvements were noted in
initiating and maintaining conversational topic, object description, and
identification of emotions.

Summary
There is an impressive body of evidence demonstrating that carefully
designed programs to facilitate social and emotional learning in typical
children result in significant gains in social, behavioral, and academic
performance. In comparison, research examining the efficacy of inter-
vention targeting social communication in children with LI is sparse.
The relatively small number of treatment studies reflects the complexity
of designing and implementing studies that assess and measure chil-
dren’s knowledge, performance, and growth within and across varied
domains of development. Both treatment and assessment demand
consideration of multiple behaviors within authentic communicative
contexts. Nevertheless, recent studies provide evidence that social com-
munication interventions can be effective at facilitating growth, at least
to the point where stakeholders observe a positive difference. Additional
efficacy research is needed to identify the most critical social commu-
nication abilities to target, to refine our treatment approaches, and to
determine the most effective intensity and duration of treatment.

CASE STUDY OUTCOMES

Like most children with LI, Jennie presented with complex educational
needs. On one hand, she demonstrated the kinds of structural language
deficits that have traditionally been associated with LI. Facilitating Jen-
nie’s language structure and expanding her vocabulary seemed essential
to her academic progress. That was only part of the picture, however.
Jennie’s difficulty with pragmatics and social cognition limited her ability
to comprehend academic content, to understand stories and events, to
participate in learning contexts, and to form positive relationships with
her peers.
Jennie’s abilities and challenges could best be addressed within a social
communication approach. Such an approach allowed a broad perspec-
tive on Jennie’s development and the integration of language processing,
pragmatic, and social cognition goals in intervention. An interven-
tion program was designed to facilitate simultaneously the production
of complex sentences, the acquisition of new vocabulary (including
 Children With Language Impairment • 243

emotion words), the comprehension of story structures, the interpreta-

tion of emotion cues, and the association of events and situations with
the emotions they might elicit. Treatment sessions were built around a
trio of components. The first involved storybooks with clear event struc-
tures and prominent emotional content. The clinician shared a book
with Jennie, emphasizing (a) the facial expressions of emotions pictured,
(b) the sources of emotions, (c) the emotion labels, (d) the sentence
structures used to link scenarios with the emotions they elicited, and
(e) the outcomes of prosocial behaviors of characters. Jennie then partici-
pated in an enactment using toys and prompts. She was encouraged to
use appropriate sentence structures to express and explain the emotions
and motivations of characters and to model emotion cues including facial
expressions.
The second component consisted of a brief segment of direct instruc-
tion on various aspects of emotion understanding such as learning emo-
tion words, interpreting emotion cues, or modeling facial expressions
of emotion. The third component involved a journaling activity. Jennie
dictated sentences to the clinician relating the main idea of the story,
what she had liked about the session, and what she found challenging.
The clinician modeled appropriate sentence structures and words, read
Jennie’s dictation back to her, and assisted Jennie in “revising” her dicta-
tion as needed. Jennie was encouraged to draw a picture, write a letter or
word, or put a sticker in her journal. Jennie found these activities chal-
lenging, but she gradually learned to focus on the emotional content of
the stories, the perspectives of the characters in the stories, a variety of
emotion words, and more appropriate language structures. Within a few
months, her repertoire of emotion words began to expand, as did her
ability to recognize and correctly label emotion. These gains supported
her comprehension of stories. It was clear, however, that Jennie would
continue to need intervention emphasizing the integration of language
and social and emotional learning.

DISCUSSION QUESTIONS
1. How has the conceptualization of language impairment (LI)
evolved over time?
2. What is social communication and how is it different from
pragmatics?
3. How does “cognitive” theory of mind differ from “affective” the-
ory of mind?
4. What are some common social tasks that are difficult for chil-
dren with LI?
244 • Fujiki and Brinton

5. What are some of the social and emotional problems that chil-
dren with LI may experience?
6. What are some reasons to believe that limited language is not
the only factor that leads to social and emotional problems in
children with LI?
7. Describe some aspects of emotional competence that are dif-
ficult for children with LI.
8. Why is it important to consider “stakeholders” as well as the
child when assessing the social communication skills of a child?
9. What type of questions should be asked about social cognition
when performing a social communication assessment?
10. Are social and emotional learning programs for typical children
effective? What can these programs tell us about similar pro-
grams for children with LI?
11. What do single subject research studies add to our understand-
ing of the efficacy of social communication interventions?

CLINICAL RESOURCES
American Psychiatric Association. Definition of social communication disor-
der: www.dsm5.org/Documents/Social%2520Communication%2520Dis
order%2520Fact%2520Sheet.pdf
American Speech-Language-Hearing Association, Social Communication
Disorders in School-Age Children. Clinical topics: www.asha.org/
Practice-Portal/Clinical-Topics/Social-Communication-Disorders-in-
School-Age-Children/
American Speech-Language-Hearing Association, Social Communication
Benchmarks: www.asha.org/uploadedFiles/ASHA/Practice_Portal/Clini-
cal_Topics/Social_Communication_Disorders_in_School-Age_Children/
Social-Communication-Benchmarks.pdf
American Speech-Language-Hearing Association, Social Communi-
cation Components of Social Communication: www.asha.org/uploaded
Files/ASHA/Practice_Portal/Clinical_Topics/Social_Communication_
Disorders_in_School-Age_Children/Components-of-Social-Commu
nication.pdf

NOTE
1
In this chapter we refer to developmental language difficulties in the face
of relatively typical nonverbal cognitive abilities using the term “language
impairment” rather than specific language impairment in recognition
of the fact that the impairment is not as specific as once believed. We
 Children With Language Impairment • 245

occasionally use the term SLI when authors have used it to describe the
children they have studied, however.

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 9
SOCIAL COMMUNICATION ASSESSMENT AND
INTERVENTION FOR CHILDREN WITH
ATTENTION PROBLEMS
Geralyn R. Timler and Katherine E. White

The language and communication difficulties in children with ADHD

may remain undetected unless language functioning is made a formal
part of the diagnostic assessment for ADHD.
—Tannock and Schachar (1996, pp. 147–148)

As most therapies are verbally based, including the cognitive behavio-

ral and social skills training techniques often applied to children with
ADHD, it is notable that language competence is rarely evaluated sys-
tematically before such therapies are undertaken.
—Cohen et al. (2000, p. 360)

LEARNING OBJECTIVES
Readers will be able to
1. State the incidence/prevalence rates for Attention-Deficit/
Hyperactivity Disorder (ADHD) and Fetal Alcohol Spectrum
Disorder (FASD).
2. Describe the behavioral phenotype that leads to diagnoses of
ADHD and FASD.
3. Summarize language and social communication profiles of chil-
dren with ADHD and children with FASD.

252
 Children With Attention Problems • 253

4. Describe evidence-based assessment and intervention practices

for children with ADHD and FASD.
Gregory (Greg) is a 7-year-old who has a diagnosis of Attention-Deficit/
Hyperactivity Disorder (ADHD), articulation disorder, and language
disorder. Greg and two younger brothers, ages 5 and 2, live with both
parents. When Greg was 18 months old, his parents reported that he
seemed “more active” and was much less likely to respond to “no” than
were his siblings. In addition, Greg was “not able to get the sounds of
words out.” When Greg was 3, their pediatrician thought that some of
Greg’s behavioral problems might be related to his communication dif-
ficulties and recommended Greg be evaluated by a speech-language
pathologist (SLP). Greg was diagnosed with a speech sound disorder
and subsequently received speech therapy services at a local special
education preschool program. Although Greg’s communication skills
began to improve, his parents had increasing concerns about his behav-
ior. Greg was easily distracted by sounds in the neighborhood even
when he was watching television. He continued to be “on the go” both
at home and in his group therapy sessions. Just after his fourth birth-
day, Greg’s parents had him evaluated by a neurologist. The neurologist
and an interdisciplinary team of a pediatrician and clinical psychologist
confirmed Greg’s speech disorder and suggested that Greg might have
ADHD and be at high risk for dyslexia. Because of his ADHD diagno-
sis, Greg was eligible for special education services under the category
of “Other Health Impairment.” His speech services intensified in kin-
dergarten and primarily focused on increasing speech intelligibility. In
addition to school-based services, Greg’s parents have sought out fur-
ther support from a university clinic and an intensive summer program
aimed at supporting literacy skills. At the end of first grade, his parents
identified that he is “especially good at math” but that reading is difficult
for him. Although Greg likes school, his parents have some emerging
concerns about his peer relationships. They report that Greg has few
friends. At home, he frequently interrupts his brothers or ignores their
questions to him.
Greg’s attentional and behavioral difficulties and communicative
development are typical of some children with ADHD. Approximately
half of all school-age children and adolescents with ADHD have a
co-occurring communication disorder (Mueller & Tomblin, 2012). Lan-
guage impairment is one of the most common co-occurring diagnoses
in children with ADHD. Fortunately, Greg’s attentional problems and
communicative disorders were diagnosed relatively early—during the
preschool years. Even though children with ADHD are at higher risk for
254 • Timler and White

communicative difficulties than are children without ADHD, these dif-

ficulties are likely to remain unidentified unless a systematic screening
protocol is implemented at the time the child’s behavioral difficulties are
evaluated. Suggestions for such a protocol are provided in a later section
of this chapter.
Children with ADHD are not the only population of children with
attentional problems who are served by SLPs. Children prenatally
exposed to alcohol who receive one of several diagnoses under the
umbrella term of Fetal Alcohol Spectrum Disorder (FASD) often have
co-occurring attention deficits and social communication problems.
Descriptions of the diagnostic characteristics, incidence, and speech and
language profiles of children with ADHD and FASD are presented in
subsequent sections. The Assessment and Intervention sections include
overlapping recommendations and guidelines for addressing the social
communication concerns of children with ADHD and FASD.

ADHD: DEFINITIONS, INCIDENCE, AND PREVALENCE

Definitions
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelop-
mental disorder that is diagnosed based on the presence of develop-
mentally inappropriate levels of hyperactivity/impulsivity or inattention
(American Psychiatric Association [APA], 2013). Hyperactivity refers
to excessive motor activity including excessive fidgeting, tapping, or
talking. Impulsivity is characterized by acting without thinking about
the possible harm of an action or acting quickly to get an immediate
reward even when the reward might be greater if the individual delays
the action. Finally, inattention includes behaviors such as wandering off
task because of difficulties sustaining focus and persistence; these behav-
iors are not due to comprehension difficulties or purposeful noncompli-
ance. Children and adults may receive one of three specified diagnoses
of ADHD including predominantly inattentive presentation (i.e., six or
more symptoms of inattention for at least 6 months and fewer than six
symptoms of hyperactivity or inactivity for at least 6 months), predomi-
nantly hyperactive/impulsive presentation (i.e., six or more symptoms
of hyperactivity or inactivity) or combined presentation. The severity
of the impact of inattentiveness and/or hyperactivity/impulsivity can be
rated as mild, moderate, or severe depending on the level of impact the
symptoms have on social and occupational functioning (APA, 2013).
The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text
 Children With Attention Problems • 255

rev.; DSM-IV-TR; 2000) required that the symptoms of ADHD be pre-

sent in a child by the age of 7 and that the child demonstrate “clinically
significant” impairment in at least two settings such as school, work,
or home. The recently published Diagnostic and Statistical Manual of
Mental Disorders (5th ed.; DSM-5; APA, 2013) has modified the inclu-
sionary criteria to behaviors that “interfere with or reduce the quality
of social, academic, or occupational functioning” prior to the age of
12 years (p. 60).
Importantly, children with ADHD do not usually demonstrate too
little attention; rather the difficulty is in regulating attention. These dif-
ficulties are characterized by problems inhibiting attention to nonrel-
evant stimuli (e.g., background noises in the classroom such as a noisy
ceiling fan) and thus, focusing too intensely on extraneous stimuli while
ignoring relevant stimuli such as teacher instruction. In fact, ADHD has
been described as a disorder of “too much attention to too many things”
with limited focus on any one task (Contractor, Mayhall, Pataki, John-
son, & Windle, 2013, p. 2).
A widely studied model proposed to account for the attention regula-
tion difficulties in children with ADHD is the executive functions model
(Barkley, 1997). Executive functions (EF) refer to a variety of higher
order cognitive processes that support self-regulation when planning,
attending, conducting, persevering, evaluating/revising, and complet-
ing a goal directed behavior or task. Some of these cognitive processes
include inhibition, working memory, planning, cognitive flexibility, and
nonverbal fluency (Pennington  & Ozonoff, 1996). A  number of stud-
ies have revealed that children with ADHD have particular difficul-
ties in tasks that require inhibition, such as delaying the start of—or
stopping—a response that has been started (Barkley, 1997; Willcutt,
Doyle, Nigg, Faraone, & Pennington, 2005); however, problems in spa-
tial working memory, planning, and task vigilance have also been found
in some children (Pennington & Ozonoff, 1996; Willcutt et al., 2005).
Because EF deficits are so common in children with ADHD, it has
been hypothesized that these deficits underlie the social communication
difficulties in children with attention problems (Tannock  & Schachar,
1996). This hypothesis is intuitively appealing when one considers the
complex demands of social interactions. Social interactions may require
one to wait for a turn, ignore teasing, or avoid telling a peer that some-
thing said was “stupid” even if you believe it was! Although EF deficits
likely contribute to social communication deficits in some children with
ADHD, recent evidence has revealed that not all children with ADHD
demonstrate executive function deficits during lab-based EF perfor-
mance tasks (Sonuga-Barke  & Halperin, 2012; Willcutt et. al., 2005).
256 • Timler and White

Moreover, at least one study has found no relationship between per-

formance on EF experimental tasks and pragmatic language abilities in
children with ADHD (Parigger, 2012); however, some studies do find
an association when parent ratings of EF and pragmatic language abili-
ties are examined (e.g., Nilsen, Mangal, & MacDonald, 2013). Current
understanding of the relationship between ADHD symptoms and EF
disorders is that while EF disorders are strongly associated with ADHD,
the evidence does not “support the hypothesis that EF deficits are the
single necessary and sufficient cause of ADHD in all individuals” (Will-
cutt et al., 2005, p. 1342). As such, EF deficits likely contribute to social
communication deficits in some but not all children with ADHD.
A second model, the motivation-based dysfunction model, has been
developed to account for the impulsivity piece of ADHD (Sonuga-Barke,
2005). One version of this model focuses on the research and clinical
evidence that some children with ADHD have difficulty waiting for
rewards and prefer receipt of immediate rewards even when slightly
longer delays would result in much larger rewards (Lopez-Vergara  &
Colder, 2013). Another component of this model is that some children
with ADHD show a hypersensitivity to punishment such that anxiety in
expectation of a punishment (e.g., losing tokens or points) reduces task
performance.
The EF and the motivation-based dysfunction models provide unique
implications for assessment and treatment of social communication
disorders in children with various presentations of ADHD. Assessment
and intervention strategies to account for these models are described in
the Assessment and Treatment sections.

Incidence and Prevalence

Due to the recent changes in the DSM-5 (APA, 2013) diagnostic cri-
teria for ADHD, the incidence of ADHD is expected to rise (Lowry,
2013). Current estimates of prevalence in the United States are that 11%
of school-age children, ages 4 to 17, have ADHD (Centers for Disease
Control and Prevention [CDC], 2013a). Prevalence rates vary across
the US with western states reporting that 6% of school-age children are
affected while southern and eastern states report rates above 10% (CDC,
2013a). In any case, ADHD is considered the most common neurobe-
havioral disorder of childhood. Boys are more likely to be diagnosed
with ADHD than girls; recent estimates suggest that 13.2% of school-age
boys in the US have ADHD (CDC, 2013a), reflecting an approximate
2:1 ratio of boys to girls (APA, 2013). When girls do receive a diagnosis
of ADHD, they are more likely than boys to be diagnosed with inatten-
tive presentation (APA, 2013).
 Children With Attention Problems • 257

International estimates of ADHD are highly variable (for review, see

Storebø et al., 2011). For example, reported rates in the United Kingdom
are that 3.6% of boys and 0.9% of girls, ages 5 to 15 years have ADHD
(Ford, Goodman, & Meltzer, 2003). In one study from Columbia, South
America, reported prevalence was much higher: 19.9% for boys and
12.3% for girls (Pineda, Lopera, Palacio, Ramirez,  & Henao, 2003).
One explanation for varying rates suggests that ADHD is a socially,
culturally, and geographically influenced condition (Faraone, Sergeant,
Gillberg, & Biederman, 2003; Polanczyk, Silva de Lima, Horta, Bieder-
man, & Rohde, 2007). Inspired by this explanation, Faraone et al. (2003)
and Polanczyk et al. (2007) conducted systematic reviews of the preva-
lence literature and found that overall, there was no significant differ-
ence between the prevalence of ADHD in the United States compared
to other geographic locations. Although some areas did show relatively
lower rates, there were too few studies available for review from these
locations to make any concrete conclusions from the data (Faraone
et  al., 2003; Polanczyk et  al., 2007). Polanczyk and colleagues (2007)
suggest that “the ADHD/HD worldwide-pooled prevalence is 5.29%
(95% CI=5.01–5.56)” (p. 946) and concluded that given these data, an
individual’s culture or background does not make him or her any more
or less likely to be diagnosed with ADHD. Overall, the worldwide vari-
ability of the prevalence of ADHD is most likely due to factors such
as diagnostic criteria used, extent to which the elements of the criteria
were applied, methods used to make a diagnosis, and characteristics of
the sample population (Faraone et al., 2003). Yet, differences in cultur-
ally appropriate practices and expectations for child behavior cannot be
ruled out as contributing to small variations in geographic and ethnic
prevalence rates (APA, 2013).

ADHD: LANGUAGE AND SOCIAL PRAGMATIC

COMMUNICATION DEVELOPMENT
Overview
Children with ADHD represent a highly heterogeneous group. Some
children have typical speech and language development while others
have deficits in one or more areas of speech, language, and literacy skills
(see reviews by Boada, Willicut, & Pennington, 2012; Mueller & Tom-
blin, 2012; Redmond, 2004; Tannock  & Schachar, 1996; Timler 2014).
Although one of the most common co-occurring deficits in children with
ADHD is language impairment (LI), estimates about the rates of this
258 • Timler and White

co-occurrence vary widely; reported co-occurrence rates have ranged

from approximately 33% to 90% (Cohen et al., 1998; Gualtieri, Koriath,
Van Bourgondien, & Saleeby, 1983; Timler, 2014; Tirosh & Cohen, 1998).
Rates vary by referral source and the focus of the communication assess-
ment (Mueller & Tomblin, 2012). Co-occurrence rates are lower if the
focus is on syntactic and semantic skills; rates are higher if the focus is
on pragmatic language skills because difficulties in social interaction are
a core deficit for children with ADHD. In fact, the DSM-5 lists several
behavioral symptoms of ADHD that overlap with social (pragmatic) com-
munication deficits including “excessive talking, “little attention to detail,”
and “frequent interruptions” (APA, 2013). It is likely that co-occurring LI
in many children with ADHD remains unrecognized because LI, in gen-
eral, is under-identified in school-age children (Tomblin et al., 1997). As
such, the speech-language pathologist has an important role to play in
the interdisciplinary assessment of children with ADHD, in particular to
screen for potential language impairment in children who are referred for
concerns with behavior and poor academic performance.

Language Development and Disorders in Children With ADHD

Both delays in the onset of first words and the emergence of sentences
have been reported in some toddlers and preschoolers who later receive
a diagnosis of ADHD (Bruce, Thernlund  & Nettelbladt, 2006; Tan-
nock & Schachar, 1996). Initial referral for young children is likely to
focus on expressive language concerns. Yet, when parents are asked
to complete formal report measures that include receptive language
items (e.g., “Does your child have trouble understanding explanations/
instructions?” “Does your child misinterpret what is said?”), they rate
these items just as negatively as (or more so than) expressive language
items such as “Does your child have difficulty carrying on a conversa-
tion?” (Bruce et al., 2006).
Lower parent ratings of communication skills in multiple domains
underscore the importance of comprehensive assessment of receptive
and expressive language skills in content (e.g., vocabulary, figurative
language), form (e.g., syntax), and use (e.g., narration, conversation) of
language. Children with ADHD make more inferencing errors in ref-
erential comprehension tasks than children without ADHD (McInnes,
Humphries, Hogg-Johnson, & Tannock, 2003; Nilsen et al., 2013). Some
children have specific deficits in comprehension of figurative language
(e.g., “The young girl held the baby like a fine china plate”); these defi-
cits appear to contribute to compromised performance in social prob-
lem solving tasks, such as formulating less appropriate solutions to
hypothetical conflicts with peers (Im-bolter, Cohen, & Farnia, 2013).
 Children With Attention Problems • 259

In addition to identification of difficulties in receptive language tasks,

research efforts have focused on identifying the expressive language pro-
file of school-age children with ADHD. Specifically, one research aim
has been to examine whether children with ADHD and co-occurring
LI have more impaired linguistic profiles than children who only have
LI. Redmond and colleagues (Redmond, Ash,  & Hogan, 2013) tested
children who had both ADHD and LI and compared their performance
on several linguistic measures to children with ADHD only, children
with LI only, and typically developing controls. Children with both
ADHD and LI had difficulty in repetition tasks and verb tense accuracy;
however, they did not have more difficulties than children with LI who
did not have attention deficits. In other words, an ADHD diagnosis did
not seem to intensify the symptoms of LI in young school-age children
who have both conditions. Moreover, the performance of children with
ADHD only was similar to age-matched typical peers.
A second focus of research has been to examine whether the syntactic
and semantic language profiles of children with ADHD differ from chil-
dren with LI who do not have attentional issues. In a series of systematic
investigations, Redmond and his colleagues have revealed that children
with ADHD who were carefully screened to rule out a co-occurring LI at
the time of testing, did not demonstrate clinical markers of LI (Redmond,
2004, 2005; Redmond, Thompson, & Goldstein, 2011). Specifically, only
children with LI demonstrated lower performance on tasks that required
repetition of nonsense words and sentences of varying length and gram-
matical complexity. Moreover, whereas young school-age children with LI
made errors in marking of verb tense such as omitting the past tense –ed,
children with ADHD did not make these errors.
Pragmatic language skills of children with ADHD have been exam-
ined in narrative and conversational discourse. Narrative samples elic-
ited via standardized tests (e.g., the Test of Narrative Language [TNL];
Gillam & Pearson, 2004) and wordless picture books reveal that some
children with ADHD, particularly those who have a co-occurring LI,
produce shorter stories, have fewer story grammar elements, and more
cohesion errors than typically developing children (Cohen et al., 2000;
Luo & Timler, 2008; Parigger, 2012; Vallance, Im, & Cohen, 1999). Cohe-
sion is maintained by linguistic devices that tie meaning across utter-
ances such as pronouns and conjunctions. In the sentences “Sam and
John went climbing” and “He fell down,” he is a cohesion error because
we don’t know which boy fell down).
The conversation samples of school-age children with ADHD
are likely to be characterized by inappropriate pragmatic language
behaviors such as interrupting the communication partner, providing
260 • Timler and White

nonspecific and insufficient feedback to that partner, and producing

more sentence revisions and repetitions, sometimes referred to as mazes
or speech disruptions (Cohen et al., 2000; Kim & Kaiser, 2000; Purvis &
Tannock, 1997; Redmond, 2004).
In summary, the clinical implications of these findings are that non-
word repetition, sentence recall, and tense-marking tasks can provide
accurate discrimination of young children with ADHD who do and do
not have co-occurring LI in semantic and syntactic domains (Redmond
et al., 2013). Children with ADHD usually do not have syntactic defi-
cits unless they have a co-occurring LI. Social (pragmatic) communi-
cation difficulties in inferencing tasks, conversation, and narration are
core deficits for many children with ADHD even in the absence of LI in
syntactic domains.

FASD: DEFINITIONS, INCIDENCE, AND PREVALENCE

Definitions
One of the most serious threats to a developing fetus during pregnancy
is exposure to alcohol. The CDC (2011) has stressed that alcohol con-
sumption during pregnancy is not safe at any time or in any amount. In
fact, the US Surgeon General advised that complete avoidance of alco-
hol before or during pregnancy is the only guaranteed way to prevent
FASD (National Institutes of Health, 2010).
FASD is an umbrella term that includes a range of diagnoses asso-
ciated with prenatal alcohol exposure. Fetal Alcohol Syndrome (FAS)
is the most severe type of FASD. The Institute of Medicine (Stratton,
Howe,  & Battaglia, 1996) established four diagnostic criteria for FAS:
(a) growth deficiency including growth delays during gestation and the
first 12 years of life; (b) the FAS facial phenotype including short pal-
pebral fissures, small midface, flat philtrum, and thin upper lip; (c) evi-
dence of central nervous system dysfunction characterized by a broad
range of possible deficits including seizure disorder, intellectual disabil-
ity, learning disabilities, and ADHD; and (d) gestational alcohol expo-
sure, which may or may not be confirmed. Severity codes for each of
these criteria have been developed to create a four-digit diagnostic code
that indicates the magnitude of expression of each feature ranked on a
4-point scale with 1 reflecting a complete absence of the FAS feature and
4 reflecting the full manifestation (Astley, 2004). For example, a child
with a four-digit code of 3344 would receive a corresponding diagnosis
of atypical FAS. The individual digits, respectively, represent moderate
 Children With Attention Problems • 261

growth deficiency, moderate expression of the FAS facial features, clear

evidence of organic brain damage, and confirmed risk of significant ges-
tational alcohol intake as provided by the birth mother or an individual
who directly observed maternal drinking.
Although FAS has received the most attention in the empirical lit-
erature, over time researchers have developed a better understanding
of other diagnostic categories within the spectrum. These are known
as Alcohol-Related Effects and include Alcohol-Related Neurodevelop-
mental Disorder (ARND) and Alcohol-Related Birth Defects (ARBD;
Stratton et al., 1996). The Substance Abuse and Mental Health Services
Agency (SAMHSA; 2004) reports that individuals with one (or both)
of these Alcohol-Related Effects exhibit characteristics typical of prena-
tal exposure to alcohol, but do not present the facial anomalies of FAS.
An individual with ARND may experience abnormal central nervous
system (CNS) development and/or delays in behavioral and cognitive
development struggling specifically with attention deficits, poor visual
focus, hyperactivity, delayed speech and language development, and
learning disabilities (SAMHSA, 2004; Stratton et al., 1996). In contrast,
an individual with ARBD may experience bone, kidney, heart, eye, and/
or hearing defects (SAMHSA, 2004).
Of importance to SLPs who serve individuals with prenatal alcohol
exposure, is that the specific diagnostic classification (i.e., FAS, ARND,
or ARBD) does not predict the severity of the functional deficits that can
have an impact on a child’s learning and social interactions. These func-
tional deficits include “hyperactive behavior, difficulty paying attention,
poor memory, difficulty in school (especially in math), learning disabili-
ties, speech and language delays, intellectual disability or low IQ, [and]
poor reasoning and judgment skills” (CDC, 2011, p. 1), in addition to
“lack of impulse control, lack of sustained close relationships, [and]
inability to recognize social or physical risk” (Woods, Greenspan,  &
Agharkar, 2011, pp. 17–18). Individuals with FASD show impairments
in several areas of executive functioning including cognitive flexibility,
response inhibition, planning, reasoning, and working memory (see
reviews by Coggins, Timler,  & Olswang, 2007; Rasmussen, Wyper,  &
Talwar, 2009). Some of these symptoms are commonly found in other
disorders such as ADHD, which complicates the process of diagnosing
an FASD, particularly when alcohol consumption cannot be confirmed.

Incidence and Prevalence

Deficits associated with prenatal alcohol exposure persist throughout
life. Prevalence, rather than incidence, is usually used to describe FASD
rates among all age groups (May & Gossage, 2001). In the data presented,
262 • Timler and White

we use the authors’ terminology. More information is available about

FAS than other conditions. FAS prevalence rate in the US is “at least 2
to 7 per 1,000” (May et al., 2009, p. 189). The CDC has recently funded
several surveillance programs to update prevalence rates for cases of
FAS, ARND, and ARBD (CDC, 2010). It is likely that the number of
cases of FASDs across the entire spectrum is significantly greater, possi-
bly even three times greater, than what has been reported for FAS alone
(CDC, 2012).
Differences in demographics and social circumstances influence
prevalence rates, as the occurrence of FASD is not uniformly examined
among all socioeconomic (SES) levels and ethnic/racial backgrounds
(May & Gossage, 2001). Prevalence rates vary across American Indian,
Native Hawaiian, and Alaska Native populations and are reported to
be approximately 1.5 to 2.5 per 1,000 live births (SAMHSA, 2007). FAS
prevalence rates in Alaska alone are much higher; rates of 5.6 per 1,000
live births for American Indians/Alaska Natives have been reported.
The historical factors of violence, oppression, displacement, and loss of
self-determination along with poverty and teen pregnancy are thought to
contribute to the drinking culture of some Native American populations
(SAMHSA, 2007). Another high risk population in the US is children in
foster care; these children are “10 to 15 times more likely than the gen-
eral population to have FASD” (Astley, Stachowiak, Clarren, & Clausen,
2002, p. 712). Although certain populations appear to be at higher risk
than others in the US, clinicians must be aware that children from any
cultural background are at risk of FASD if they have been prenatally
exposed to alcohol. Universal factors that influence the risk of FASD
include the mother’s socioeconomic status, employment status, educa-
tion, relationship status, health state, additional drug use, cultural norms,
and household environment, among others (May & Gossage, 2011).
International rates of FAS are highly variable and many countries
are just beginning surveillance studies. For example, Canadian reports
have typically relied on US rates, although studies are now in progress
to identify risk within aboriginal communities and other populations
(CDC, 2013b; Fogarty International Center, n.d.). Rates in Europe
reflect some of the same demographic and social circumstances as the
US. It is estimated that approximately half of the Russian children liv-
ing in orphanages may have prenatal alcohol exposure (Woods et  al.,
2011). FAS rates in Italy, where drinking is a relatively common cultural
practice, have recently been estimated to be 4.0 to 12.0 per 1,000 (May
et al., 2011). Population-based studies suggest that South Africa has the
highest overall rate of FASD in the world (Woods et al., 2011); rates of
88 to 89 per 1,000 children” have been reported (May & Gossage, 2011,
 Children With Attention Problems • 263

p. 19). As more research is conducted and awareness about the different

types of FASD spreads, it is likely that more children will be identified
around the world and FASD rates will continue to rise.

FASD: LANGUAGE AND SOCIAL PRAGMATIC

COMMUNICATION DEVELOPMENT
A brief overview of communication concerns in children and adoles-
cents with FASD is provided here (for more comprehensive reviews
see Coggins et al., 2007; Thorne, Coggins, Carmichael Olson, & Astley,
2007).
Alcohol is a teratogen to the human brain, and as such, children
with prenatal alcohol exposure have a range of abilities and disabili-
ties. Children and adolescents with identified IQs below 70 will qualify
for special education services under the category of intellectual dis-
ability. Children and adolescents with IQs above 70 will also need
school supports because by definition, children with FASD have one
or more neurological deficits in attention, learning, and speech and
language skills.
Individuals with FASD are at increased risk for both conductive and
sensorineural hearing loss; a hearing screening should be conducted
at the time of initial diagnosis (Cone-Wesson, 2005). Most studies of
speech and language skills in children and adolescents with FASD have
examined performance on various norm-referenced language tests and
obtained a range of findings from clinically significant to within normal
limits (Thorne et al., 2007). Criterion-referenced analyses of narrative
samples have uniformly revealed difficulties in organization and cohe-
sion (Coggins et al., 2007; Thorne et. al., 2007). Parents report organi-
zational difficulties in conversation skills (Timler, Olswang, & Coggins,
2005), but fine-grained analyses of conversation samples have not yet
appeared in the research literature. Children with FASD have difficulty
in perspective-taking tasks, particularly Theory of Mind tasks (Timler
et  al., 2005). Theory of mind represents the ability to infer the men-
tal state of others, that is, to interpret and predict another’s knowledge,
intentions, beliefs, emotions, and desires, especially when this knowl-
edge may differ from the child’s own knowledge” (Timler et al., 2005,
p.  74). Parents and teachers of children with FASD almost uniformly
report concerns about social skills and problem behaviors (Streissguth
et al., 2004; Timler et al., 2005).
A final consideration for clinicians who serve individuals with
FASD is that these children and adolescents often live in adverse social
264 • Timler and White

environments characterized by poverty, multiple foster placement,

neglect (particularly if adult members in the home continue to drink),
and abuse. Coggins and colleagues (2007) have used the term double
jeopardy to describe the compound negative effects of alcohol expo-
sure and poor living conditions on children’s language and learning
development.

REFERRAL GUIDELINES AND ASSESSMENT PRACTICES

FOR CHILDREN WITH ADHD AND FASD
Medical and Psychological Referrals
SLPs who provide early intervention services are likely to see children
who have attentional issues but have not been formally evaluated.
In these situations, the role of the SLP is to carefully document and
describe the behavior concerns as well as determine through family and
teacher interviews if others share these concerns. When concerns are
documented, the SLP should refer the family to the child’s pediatrician
for further evaluation and referral to appropriate providers.
Both ADHD and FASD are complex diagnoses that are ideally ascer-
tained by a team of healthcare providers including developmental
pediatricians (e.g., to prescribe and monitor medications for attention
and other disorders and to identify the facial features of FAS), neurolo-
gists (e.g., to rule out associated seizure disorders), psychologists (e.g.,
to assess executive functioning, intelligence, and learning), and social
workers (to identify family needs and community resources). The edu-
cational needs of students with ADHD and FASD are addressed by reg-
ular and special educators and by school psychologists (who provide
testing as well as social skills training). The SLP’s roles in medical and
educational settings are to provide a comprehensive profile of the child’s
strengths and challenges in communication skills and to develop and
provide treatment for identified communication challenges (Hill, 2000).
In addition, the SLP may be asked to monitor potential fluctuations
in the student’s behavior and attention skills in response to changes
in stimulant medication or to provide evidence to support a needed
change in medication (e.g., the child appears sleepy possibly indicating
that the child is overmedicated or the child becomes more inattentive
and anxious so that the prescribed medication no longer provides opti-
mal effects).
Clinical procedures for the diagnosis of ADHD usually require com-
pletion of multiple parent and teacher report measures (American
 Children With Attention Problems • 265

Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyper-

activity Disorder, Steering Committee on Quality Improvement and
Management, 2011). Two widely used measures include the Child
Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) and the Con-
ners 3rd Edition (Conners 3; Conners, 2008). The examiner manuals
report accepted levels of reliability and validity. The CBCL has parent
and teacher versions available for rating of preschoolers and school-age
children; scaled scores are provided for social problems, attention
problems, affective problems and other DSM categories. The Conners
assessment includes long and short versions for parents, teachers, and
self-report (ages 8–48). Scaled scores are available for executive func-
tioning, externalizing, and internalizing behaviors. Both measures ask
parents to indicate the severity/frequency with which behavioral dif-
ficulties occur (e.g., cannot sit still). Higher values indicate the pres-
ence of elevated behavioral difficulties. Although SLPs do not typically
ask parents to complete these measures, an item analysis could identify
social communication skills that may need further assessment, if the
SLP has access to such measures.
In some diagnostic clinics, children are prescribed a placebo trial that
includes a mix of placebo and stimulant medication for treatment of
attention disorders. Blind placebo trials are implemented to provide evi-
dence that a medication is providing desired changes rather than illusory
changes teachers and parents want to see because they believe that the
child is medicated. In fact, studies of placebo trials have revealed that
approximately 3% to 10% of children show positive changes as meas-
ured by parent and teacher ratings of behaviors (Storebø et al., 2011).
In placebo trials, the child’s caregivers are prescribed multiple bottles
of medication that are unmarked so that the person dispensing the
prescription does not know whether the pill is medicine or a placebo.
Observers at home and school, including parents, teachers, and SLPs,
are then able to provide an unbiased assessment of the child’s responses
to the medication (or no medication). Educators and SLPs may be asked
to complete weekly or daily behavior rating scales to provide these unbi-
ased observations.

Speech-Language-Social (Pragmatic) Communication Assessment

Children with ADHD and FASD are at increased risk for speech and
language disorders and these disorders can remain unidentified when
providers, educators, and families focus on children’s behavior prob-
lems and consider learning issues as a lack of motivation rather than
potential learning and language deficits. As such, the SLP should advo-
cate for communication screening of all children with ADHD and
266 • Timler and White

FASD. Parent report measures, such as the Children’s Communication

Checklist-2 US Edition (CCC-2; Bishop, 2006), provide a time-efficient
screening method for identifying children who require further assess-
ment of comprehension skills. In a recent study of 32 young children
with ADHD, ages 5 to 8, the CCC-2 identified 100% of the children (n =
10) whose performance on a norm-referenced language test revealed a
language impairment (Timler, 2014). More details about the CCC-2 can
be found in Chapter 6.
For children who fail a language screening, a comprehensive language
assessment is necessary to identify structural language deficits (i.e.,
deficits in syntax and semantics). Standardized general language tests,
nonword repetition, sentence recall, and tense-marking tasks appear to
be particularly helpful for identifying syntactic deficits in language pro-
duction (Redmond et al., 2011, 2013). Language comprehension should
be assessed at the sentence and paragraph level to examine recall of fac-
tual information and ability to answer questions that require inferenc-
ing skills. In addition, comprehension of idioms and figurative language
should be tested. As discussed earlier, students with pragmatic language
deficits in these areas perform poorly on social problem-solving tasks
(e.g., What could you say and do here?); these tasks are often used in
social communication interventions to teach students how to approach
problematic social situations.
Comprehensive assessment of social (pragmatic) communication defi-
cits requires a variety of assessment tools including norm-referenced tests,
rating scales (e.g., the CCC-2 is particularly useful), criterion-referenced
procedures and naturalistic observations at home and school. Some of
the procedures used for social communication assessment of children
with language impairments are also appropriate for children with atten-
tional issues; readers are encouraged to review the assessment sections
in Chapters 6 and 8 for descriptions of relevant assessment tools.
Because children with attention problems frequently have difficulty
managing longer discourse units, two data-based methods widely used
in the ADHD and FASD literature to identify pragmatic language defi-
cits include collection of conversation and narrative samples. Analysis of
conversation samples using the Pragmatic Protocol (Prutting & Kirch-
ner, 1987) has revealed inappropriate speech-act pair analysis (i.e., the
child’s utterance is not responsive to the communication partner’s utter-
ance), interruption/overlap with the partner, inappropriate feedback to
the partner, poor cohesion, and reduced specificity (Cohen et al., 1998,
2000; Kim & Kaiser, 2000; Vallance et al., 1999). The Pragmatic Protocol
or a similar checklist for analysis of conversation samples is likely to not
only provide evidence of children’s social communication difficulties,
 Children With Attention Problems • 267

but guide intervention planning, particularly if multiple language sam-

ples are obtained across interactions with adults and peers. Narrative
samples have been collected using a variety of elicitation techniques
including the Test of Narrative Language (Gillam  & Pearson, 2004),
wordless picture books (e.g., Mayer, 1969) and videos. Relevant analy-
sis techniques include cohesion and story grammar analysis (e.g., see
Cohen et al., 2000; Luo & Timler, 2008; Thorne et al., 2007). Narrative
samples provide a clinically efficient method for viewing children’s plan-
ning and organization skills as well as perspective taking abilities (e.g.,
to account for the needs of the listener when telling stories).

Assessment of Executive Functions

Neuropsychologists and clinical psychologists administer norm-referenced
tests to assess executive functions in children and adolescents. One test is
the Comprehensive Assessment of Neuropsychological Development in
Children–2nd Edition (NESPY-2; Korkman, Kemp, & Kirk, 2007) a devel-
opmental neuropsychological assessment for children ages 3 to 16 years.
The executive functioning/attention domain includes seven subtests
which assess various EF processes of inhibition, self-regulation, monitor-
ing, vigilance, selective and sustained attention, maintenance of response
set, planning, flexibility in thinking and figural fluency. Other NEPSY-2
domains include language and communication, sensorimotor functions,
visuospatial functions, learning and memory, and social perception. This
test is not usually administered by SLPs; however, the neuropsychologist’s
summary of a child’s NEPSY-2 performance can provide direction for fur-
ther communication assessment.
Although the language tests administered by SLPs do not typically
provide direct assessment of EF, SLPs can document test behaviors
that reveal something about children’s EF skills. For example, the SLP
can note whether a child self-corrects, asks for repetition of direc-
tions, answers too quickly or slowly, is distracted by extraneous sounds,
repeats directions, or displays little evidence of planning for extended
oral and written tasks (e.g., narratives). In other words, the SLP can note
the child’s self-regulation behaviors during formal assessment.
Similar to pragmatic language assessment, there is not one single test
or subtest that provides a comprehensive picture of executive function
skills or specific guidelines for functional treatment plans. The problem
is that performance-based tests, which focus on one or more aspects of
executive functioning, provide some degree of structure and organiza-
tion for the student. This structure may mask executive function deficits
that are more apparent in the student’s everyday natural environment
(Wittke, Spaulding,  & Schechtman, 2013). As such, a student may
268 • Timler and White

score within normal limits on a performance test of EF even though

this student demonstrates difficulties in multiple aspects of task comple-
tion in school and home settings. Therefore, clinicians are encouraged
to use behavioral observations, multi-informant interviews, and ratings
scales/questionnaires to identify functional concerns and to develop
functional treatment plans.
Dawson and Guare (2010) provide an example of a comprehensive
open-ended semistructured interview with questions focusing on time
management, working memory, task and material organization, task
initiation, follow-through and flexibility, response inhibition, emotional
control, sustained attention, goal-directed persistence, and metacogni-
tion. Student and teacher versions are available. The student version
begins with an explanation of executive function skills: “I’m going to
ask you some questions about situations related to your success as a
student. All of these are situations in which you have to use planning
and organizational skills in order to be successful” (Dawson & Guare,
2010, p. 177). Situations such as “getting started with homework” and
“remembering assignments” are presented followed by suggestions for
follow-up questions to provide more details about the specific chal-
lenges of each situation.
Norm- and criterion-referenced rating scales for parents, teach-
ers, and school-age students (i.e., self-report) are also available. One
norm-referenced instrument, the Behavior Rating Inventory of Executive
Function (BRIEF: Gioia, Isquith, Guy, & Kenworthy, 2000) consists of 86
items that are rated for students, ages 5 to 18 years; separate parent and
teacher versions are available to provide comparison across informants.
A  preschool version, for ages 3 to 5, (BRIEF-P; Gioia, Espy,  & Isquith,
2003) and a student self-report version, for ages 11 to 18 years (BRIEF-SR;
Guy, Isquith, & Gioia, 2004) are also available. Acceptable levels of reli-
ability and validity are reported in the examiner manuals for each BRIEF
version. Criterion-referenced student self-rating forms provide another
method for assessing student awareness of EF skills (Dawson and Guare,
2010). For example, students rate described behaviors on a scale from
one (big problem) to five (no problem). Example items include “I act on
impulse,” “I put off homework or chores until the last minute,” and “It’s
hard for me to put aside fun activities in order to start homework.”

EVIDENCEBASED INTERVENTION PRACTICES

Interventions for children with ADHD and FASD include pharmaco-
logical (e.g., stimulant) treatments and comprehensive behavior change
 Children With Attention Problems • 269

programs to address academic, compliance, and social communication

skills. Pharmacological treatments have been reported to have a benefi-
cial effect on major symptoms of hyperactivity, impulsivity, and inat-
tention in about 80% of children treated but medication alone is not
sufficient to improve social communication skills (see Storebø et al., 2011,
for review). Social communication interventions have been developed
for implementation in pullout one-to-one or small-group sessions, in
the classroom through environmental modifications and strategies pro-
vided by the teacher in conjunction with other team members including
SLPs and parents, and at home through parent training programs. For
children with identified co-occurring deficits in semantic, syntactic, and
pragmatic skills, the SLP provides direct intervention. For children with
social communication disorders who do not have specific linguistic def-
icits, the SLP may provide co-treatment with a school psychologist or
counselor to implement a social skills or social-cognitive training pro-
gram. Finally, the SLP may serve as a consultant to parents, classroom
teachers, and other providers to suggest linguistic modifications for
social skills curricula, particularly when children receiving the curricula
have language comprehension difficulties (Hill, 2000; Redmond & Tim-
ler, 2007).

Individual/Small-Group Interventions
Individual/small-group interventions aimed specifically at children for
ADHD with language and social communication concerns has received
little empirical attention in the SLP research literature. As such, the
intervention guidelines and strategies described here are primarily
from anecdotal evidence and recommendations from clinical experts.
Most of this information is borrowed from interventions developed
for children with other diagnoses. For example, children with ADHD
and FASD may respond to interventions developed for children with
pragmatic language impairment (see Chapter  6) and structural lan-
guage impairment (see Chapter  8) although these recommendations
remain to be tested. Some of the visual support strategies for children
with autism spectrum disorder described by Fannin and Watson (Chap-
ter 7) are also likely to be relevant. Modifications in these interventions
may be needed, however, to address the executive function disorders
observed in some children with ADHD and FASD. Watson and Westby
(2003) suggest a variety of strategies to support children’s self-regulation
including use of visual cues and checklists (to supplement verbal input
and support working memory), videotaping of children’s performance
to facilitate learning and evaluation of targeted behaviors, implemen-
tation of structured daily routines, and use of systematic behavior
270 • Timler and White

modification strategies (i.e., specific corrective feedback and positive

reinforcement schedules). In addition, students with attention problems
will likely need explicit instruction in how to read the emotions of oth-
ers and express their own emotions in socially appropriate ways.
Interventions that have been adapted and tested specifically for chil-
dren with attention problems focus on teaching children how to adjust
and monitor their verbal and nonverbal behaviors during social interac-
tions, how to read subtle social cues conveying listener interest, under-
standing, and emotions, and why reading of these cues is important for
the child’s success in social interactions (Storebø et al., 2011). Common
teaching methods include multisensory input (e.g., videos, peer mod-
eling, picture and word checklists), explicit and concrete step-by-step
instruction, adult modeling of social communication targets, role-play
of targets with peers, specific and constructive feedback, and procedures
to teach children self-monitoring and evaluation. Teacher and parent
support and training are other common components of many of these
interventions in order to support generalization of children’s skills from
the small-group setting to home and classroom settings (Bertrand, 2009;
Storebø et al., 2011). Table 9.1 provides summaries of four intervention
studies; these studies are representative of the types of intervention tar-
gets and measures that have been used to facilitate social communica-
tion, executive functions, and self-regulation in school-age children
with ADHD and FASD (for comprehensive review of intervention pro-
grams and strategies see Bertrand, 2009; Storebø et al., 2011; Watson &
Westby, 2003; Zwi, Jones, Thorgaard, York, & Dennis, 2011).
For children with motivational issues who struggle with immedi-
ate need for reinforcement, the SLP and other team members will
need to identify desired rewards and optimal schedules of delivery for
these rewards. One evidence-based strategy for provision of systematic
feedback and rewards for children with ADHD is the Daily Behavior
Report Card (DBRC) intervention (Vannest, Davis, Davis, Mason,  &
Burke, 2010). This intervention usually includes four components:
clear description of the desired behavior(s) that is understood by the
child, periodic evaluation by the teacher as to the presence or absence
of the behavior, daily behavior monitoring and feedback, and parent
involvement to provide earned rewards for achievement of the behav-
ior. A recent meta-analysis of single case experimental designs revealed
a range of effect sizes for this intervention; however, the largest and
strongest effects were demonstrated when parents were involved in the
delivery of the reward for appropriate behaviors (Jurbergs, Palcic, & Kel-
ley, 2010; Vannest et al., 2010). Several of the interventions described in
Table 9.1 implemented token systems and progress charts, set up so that
TABLE 9.1 Examples of Empirically Tested Interventions for Children with FASD and ADHD
Intervention Description Outcomes
Children’s Friend- A parent-assisted intervention implemented in a community clinic for Compared to the standard of care group,
ship Training 85 children 6–12 years old with and without FASD. CFT goals focus children receiving treatment demon-
(CFT; (O’Connor on peer acceptance and friendship building facilitated through small- strated more improvement in measures
et al., 2006, 2012) group sessions and parent-supervised play dates. Parents received assessing social knowledge about appro-
handouts outlining session skills and weekly socialization homework priate behavior and had higher ratings on
assignments that included social coaching by parents during play with a self-concept measure including overall
a peer. reduction in social anxiety; no differ-
ences were observed in parent ratings
Specific CFT training modules include the following: of social skills and problem behaviors
• Conversational skills (Note: prior investigation of this program
• Peer entry implemented in a university setting found
• Expanding and developing friendship networks differences in parent rating of social skills;
• Handling teasing O’Connor et al., 2006). Children with
• Practicing good sportsmanship and good host behavior during play FASD responded to the intervention as
dates with friend well as children without FASD who have
social problems.
Neurocognitive An intervention developed for children with FASD, ages 6–12, who Compared to a no-treatment control
Habilitation Pro- are in the child welfare system and have executive function deficits. group (n = 38), children receiving treat-
gram Curriculum, Intervention aims focus on self-regulation techniques and strategies ment (n = 40) demonstrated significant
with adaptations for improving memory, cause-and-effect reasoning, sequencing, plan- increases in composite scores on a report
from the Alert ning, and problem solving. Visual imagery is used to teach children measure of executive functions and on a
Program® (Ber- that their brains are like a car engine and they can make their bodies narrative measure (i.e., treatment children
trand, 2009; Wells, run in high, low, or just-right gears. Caregivers were taught to recog- had fewer unrealistic solutions to story
Chasnoff, Schmidt, nize changes in children’s arousal problems).

(Continued )
TABLE 9.1 (Continued )
Intervention Description Outcomes
Telford, & levels, to facilitate desired emotional and behavioral responses, and to
Schwartz, 2012; engage in reciprocal and meaningful activities with their children.
Williams & Shel-
lenberger, 1996)
Contingency Man- Two classroom-based interventions were compared. Participants Random assignment to COMET or MO-
agement Training included 24 children with ADHD and 113 typically developing peers SAIC classrooms and repeated measures
(COMET) and between the ages of 6.8–9.8 years. The COMET training targeted crossover design (so that some children
Making Socially increases in socially appropriate behaviors of children through use of received both interventions) revealed
Accepting Inclu- teacher-provided expectations for desired behaviors, a token system significantly higher (more positive) results
sive Classrooms with points earned or lost based on child behavior, and explicit teacher on peer measures in the MOSAIC condi-
(MOSAIC; Mikami feedback about reasons for the exchange of points. Teachers publicly tion. Specifically, children with ADHD
et al., 2013) announced point totals of all children at the end of activities and received fewer negative nominations of
the school day, with high earners receiving public awards including “I really do not like [him or her]” and
leadership roles and prizes from a school store. The MOSAIC train- more friendship nominations from peers,
ing used the same token system but teachers provided private (not boys had fewer negative interactions at re-
public) feedback about reasons for point loss and point totals were cess (no differences were noted for girls),
shared 1:1 with children. Teachers were encouraged to model positive and boys and girls received more positive
interactions with children with ADHD focusing on praising them for messages from peers in a memory book.
interests and behaviors; teachers used daily awards to publicly discuss No significant differences were detected
children’s strengths (unrelated to children’s behavior during the day). in the reduction of inappropriate social
These strategies were implemented to encourage typical peers to view behaviors by children with ADHD.
children with ADHD more positively. MOSAIC-condition teachers
also encouraged inclusion of all children and peers lost points when
a child was ostracized; teachers created teams of children with and
without ADHD for class projects.
Intervention Description Outcomes
Play-Based Inter- A play intervention for 14 children with ADHD, ages 5–12, to facili- Pre- and posttreatment design revealed
vention tate improved social play between a child with ADHD and a typically significant gains on play assessment;
(Cordier, Munro, developing playmate. Intervention components include video mod- children also demonstrated increases in
Wilkes-Gillan, & eling (to help children understand the purpose and benefit of targeted appropriate pragmatic behaviors with a
Docking, 2013; social behaviors), video feedback (to help children recognize, under- typically developing peer during natu-
Wilkes, Cordier, stand, and regulate their emotions), and therapist and peer modeling ralistic free play observation sessions;
Bundy, Docking, & of pretend play. Parents were taught strategies to develop children’s moreover, children with ADHD and LI
Munro, 2011) social skills and were encouraged to set up playdates. showed similar improvements, suggesting
that this play intervention is appropriate
for children with co-occurring disorders.
274 • Timler and White

children had frequent reminders of progress (e.g., receipt of a token and

visual feedback of good work at least several times in a session). In addi-
tion to a focus on positive feedback, it seems important for clinicians to
identify whether an individual child finds loss of a reward particularly
aversive, so that such a loss increases the child’s anxiety and distracts
the child even further. In such cases, the clinician needs to structure
sessions and breakdown tasks into doable steps so that the child’s oppor-
tunity for the reward is optimized and the threat of punishment (i.e.,
removal or loss of points) is minimized or nonexistent.

Classroom-Based Interventions
Children with ADHD are at increased risk for peer victimization (e.g.,
bullying) and peer rejection, even in circumstances in which they are
simultaneously the instigators of such activities (Nijmeijer et al., 2008).
Hyperactivity and impulsivity have a particularly negative effect on peer
perceptions and the term reputational bias has been used to describe the
views of peers about children with ADHD; this bias is likely to remain
even after students with ADHD improve their social communication
skills (Mikami et  al., 2013). As such, some children do not have the
opportunity to display new acquired social communication skills and
to experience the positive natural consequences of appropriate social
behaviors (e.g., being allowed to enter a peer group). A protective fac-
tor against victimization is to have one or more reciprocal friendships
(Nijmeijer et  al., 2008; Redmond, 2011). The intransience of reputa-
tional bias and the protective value of reciprocal friendships underscore
the importance of addressing classroom peers when developing social
communication interventions.
Children with attentional issues do better in classrooms with clear
and consistent rules and expectations for desired behaviors. Classroom
accommodations to support academic success include posted daily
work schedules, written notices for homework assignments, quiet work
areas, and seating close to teacher and near positive peer models (Dobie
et al., 2012). Classroom climate and teacher expectations also play an
important role in supporting social communication success. Teacher
implemented strategies focus on children with attention problems and
importantly, classroom peers as well.
The study by Mikami et  al., 2013, summarized in Table  9.1, pro-
vides an example of a comprehensive teacher implemented classroom
intervention. In the Making Socially Accepting Inclusive Classrooms
(MOSAIC) condition, students with and without ADHD received tokens
for positive behaviors, lost tokens for negative behaviors, and were given
explicit feedback about the token exchange in private conversations
 Children With Attention Problems • 275

with the teacher. Feedback was private to avoid adding to negative repu-
tational bias; note that in the other treatment condition, public feed-
back was given. In addition to monitoring of student behavior, teachers
modeled positive interactions with target students and publicly praised
their strengths. Teachers also provided explicit classroom expectations
for inclusion of all students so that peers lost points if a target student
was ostracized. While no differences were noted in target students’ use
of undesirable social behaviors across both conditions, peers viewed
target students significantly more favorably in the MOSAIC condition.
As such, teacher expectation and behavior contributed to changing the
views of classroom peers towards target students.

Parent Training
Parent training programs focus on teaching strategies to promote proso-
cial and compliance behaviors, as well as positive interactions between
the parent and the child. Many parent-training programs provide
specific instruction in how to set up and monitor playdates so that chil-
dren have opportunities for positive interactions with typically develop-
ing peers. A recent meta-analysis of parent training programs revealed
mixed results. Some studies demonstrated positive changes in the reduc-
tion of parent stress and child anxiety and withdrawal while others saw
little change (Zwi et al., 2011). Parent training was a component of three
of the child focused intervention studies presented in Table 9.1 (Cordier
et al., 2013; O’Connor et al. 2012; Wells et al., 2012). Parents and caregiv-
ers attended trainings while children received direct instruction. Train-
ing content included specific instruction for helping children to regulate
their emotions and use prosocial skills. The outcomes of these studies
suggest that change is more likely when parents are partners in the inter-
vention process. More research is needed regarding how best to deliver
parent training (individual or group) and to identify parent and child
behavior that are most amenable to change in parent training programs.
Community programs that focus primarily on parent support (with-
out direct intervention for children) have also been examined. One
evidence-based parent training program is the Family Check-Up (FCU)
intervention, a program composed of periodic assessment and two inter-
vention components: motivational interviewing and teaching of family
management practices (Gill, Hyde, Shaw, Dishion,  & Wilson, 2008).
During motivational interviewing sessions, the therapist shares assess-
ment data, collected from parent rating scales and naturalistic observa-
tions, with a goal of facilitating the parent’s motivation to change the
child’s problematic behaviors. Family stressors and environmental risk
factors are identified and addressed to facilitate parent motivation (e.g.,
276 • Timler and White

resources for treating a parent’s depression are identified if needed). The

family management component focuses on teaching strategies for set-
ting limits, proactive parenting, positive reinforcement, and relationship
building. Therapists use role-play and in vivo practice in sessions with
the child and the parent; these activities are focused on specific behav-
ioral problems identified during the family and child assessment. For
example, one strategy for helping a parent to facilitate prosocial behavior
in a young child is the Good Behavior Game (Gill et al., 2008). This game
teaches parents to use a timer and instruct their children to play nicely
for 10 minutes in order to earn a reward; parents are given instruction in
how to identify reasonable and motivating rewards, explain what play-
ing nicely means, asking children to repeat this explanation, and using
a sticker chart to track the child’s positive play. Promising results from
randomized control trials have documented the efficacy of the FCU pro-
gram in families of toddlers who are at increased for conduct disorders
(Gill et al., 2008) and in families of adolescents with behavioral disor-
ders (Dishion & Kavanagh, 2003; Stormshak, Fosco, & Dishion, 2010).

CASE STUDY
Returning to the case study, Greg’s parents brought him to a University
Speech-Language-Hearing clinic. Because Greg’s difficulties in speech and
language skills (e.g., semantics and syntax) had been identified in an earlier
assessment, the current assessment focused on Greg’s pragmatic language
and social communication skills. Greg’s mother completed the CCC-2
(Bishop, 2006) and the BRIEF (Gioia et al., 2000) as did the teacher. The
Social Language Development Test–Elementary (SLDT-E: Bowers, Huis-
ingh, & LoGiudice, 2008), a norm referenced measure for 6:0–11:11 year
olds, was administered to assess Greg’s social knowledge about strategies
for interpreting and negotiating social interactions with peers. The TNL
was administered, and story grammar analyses were completed in addi-
tion to computation of standard scores. Two conversation samples with
the clinician and Greg’s brother were obtained. The results revealed mul-
tiple areas of need related to Greg’s social communication skills. The clini-
cian completed item analyses to identify specific areas of need for Greg’s
intervention plan. The clinician, Greg’s teacher and parents developed an
intervention plan to improve turn-taking skills and to decrease inappro-
priate conversation behaviors such as interrupting. All agreed to provide
reinforcement in the form of praise and opportunities for special activi-
ties at home and school when Greg was observed to implement appropri-
ate strategies for turn taking. The rules for turn taking in conversation
 Children With Attention Problems • 277

were defined and discussed and Greg developed a pictorial checklist of

these rules. The clinician modeled good and not so good turn taking, and
Greg was able to classify these models correctly. Next, Greg practiced
these skills during small-group cooperative activities in the classroom;
Greg was asked to document at least three times when he waited for his
turn to talk during each of these activities. He reported the results of his
self-monitoring to the teacher, who praised his reporting efforts but did
not comment on his reporting accuracy as she was unable to supervise
these activities consistently. Greg’s mother reviewed the turn-taking rules
at the dinner table and Greg and his brothers were asked to identify one
good turn for each sibling. Greg’s team avoided focusing on inappropriate
turns to decrease attention on negative behaviors. Greg’s mother reported
fewer outbursts from Greg during these dinnertime activities.

CONCLUSION
Children with ADHD and FASD can present complex challenges for cli-
nicians. Some children score within normal limits on norm-referenced
social language measures but have significant functional deficits in home
and school settings. Best assessment practices for intervention planning
include criterion-referenced conversation and narrative analyses; parent,
teacher, and self-report measures of pragmatic language and executive
functioning; and behavior observations at home and school. Effective
interventions to address social communication difficulties in children
with attention problems require a team effort by clinicians, mental health
providers, teachers, and parents. The fix for social communication prob-
lems is not an easy one, but it is worth the time and investment.

DISCUSSION QUESTIONS
1. What are some differences in the description of ADHD in the
DSM-IV-TR and DSM-5?
2. What is executive functioning? Describe the executive func-
tioning deficits that are observed in some children with atten-
tion problems.
3. What is the motivation-based dysfunction model? How could
an SLP account for the implications of this model when provid-
ing intervention for children with attention problems?
4. What are the language characteristics of children with ADHD
with and without co-occurring language impairment?
278 • Timler and White

5. Describe what is known about the social (pragmatic) communi-

cation profiles of children with FASD.
6. What is the role of the SLP in the assessment of children with
ADHD and FASD?
7. Describe three evidence-based assessment procedures that
could be used to identify structural language deficits in children
with ADHD who may or may not have co-occurring LI.
8. Why are conversation and narrative analyses procedures use-
ful for description of social communication profiles in children
with attention problems?
9. Describe three strategies to facilitate social communication
skills in children with attention problems.
10. What are some approaches for facilitating generalization of
social communication skills demonstrated in pullout sessions
to home and school settings?

CLINICAL RESOURCES
ADHD
ADD Warehouse: www.addwarehouse.com/
American Academy of Pediatrics: www.aap.org/healthtopics/adhd.cfm
Attitude Magazine: www.additudemag.com/
Children and Adults with Attention Deficit Disorders (CHADD), National
Resource Center on ADHD: www.chadd.org
Dawson, P.,  & Guare, R. (2010). Executive skills in children and adolescents:
A practical guide to assessment and intervention (Guilford Practical Inter-
vention in Schools Series, 2nd ed.). New York, NY: Guilford Press.
Dobie, C., Donald, W. B., Hanson, M., Heim, C., Huxsahl, J., Karasov,
R., . . . Steiner, L. (2012). Diagnosis and management of attention defi-
cit hyperactivity disorder in primary care for school-age children and
adolescents. Bloomington, MN: Institute for Clinical Systems Improve-
ment. Available from the Institute for Clinical Systems Improvement
website: https://www.icsi.org/guidelines__more/catalog_guidelines_
and_more/catalog_guidelines/catalog_behavioral_health_guidelines/
adhd/
K12 Academics: www.k12academics.com/addadhd.htm
National Institutes of Mental Health: www.nimh.nih.gov/health/topics/
attention-deficit-hyperactivity-disorder-adhd/index.shtml
SchoolBehavior.com: www.schoolbehavior.com/disorders/attention-deficit-
hyperactivity-disorder
 Children With Attention Problems • 279

FASD
Centers for Disease Control and Prevention (CDC): Fetal Alcohol Spectrum
Disorders (FASDs) website www.cdc.gov/ncbddd/fasd/index.html
Blaschke, K., Maltaverne, M.,  & Struck, J. (2009). Fetal alcohol spectrum
disorders education strategies: Working with students with a fetal
alcohol spectrum disorder in the education system. Retrieved from
www.usd.edu/medical-school/center-for-disabilities/fetal-alcohol-
spectrum-disorders-education-strategies-handbook.cfm
Medline Plus Fetal Alcohol Spectrum Disorders web page with additional
resources: www.nlm.nih.gov/medlineplus/fetalalcoholspectrumdisor
ders.html
National Institutes of Health: National Institute on Alcohol Abuse and Alcohol-
ism (NIAAA) website: www.niaaa.nih.gov
National Organization on Fetal Alcohol Syndrome (NOFAS): www.nofas.org
Recovering Hope (Video) by the Substance Abuse and Mental Health Services
Administration: www.youtube.com/watch?v=m7zfJCW9Yco
Substance Abuse and Mental Health Services Administration (SAMHSA):
Fetal Alcohol Spectrum Disorders Center for Excellence website: www.
fascenter.samhsa.gov
US National Library of Medicine, National Institutes of Health: Fetal Alcohol
Spectrum Disorders website: www.nlm.nih.gov/medlineplus/fetalalco
holspectrumdisorders.html

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 10
SOCIAL COMMUNICATION ASSESSMENT AND
INTERVENTION FOR CHILDREN EXPOSED
TO MALTREATMENT
Deborah A. Hwa-Froelich

I believe the best service to the child is the service closest to the child,
and children who are victims of neglect, abuse, or abandonment must
not also be victims of bureaucracy. They deserve our devoted attention,
not our divided attention.
—Guinn (n.d.).

LEARNING OBJECTIVES
Readers will
1. Become aware of incidence/prevalence statistics and different
types of maltreatment.
2. Learn about the language development of children exposed to
maltreatment and why they are at increased risk of language
impairment and social communication disorder.
3. Be able to describe an evidence-based, transdisciplinary assess-
ment and intervention approach for children exposed to mal-
treatment who have a social communication disorder.
4. Gain knowledge as to how cultural differences may impact the
treatment of children.

287
288 • Hwa-Froelich

CASE STUDY
Harry is a 4-year-old boy adopted from China when he was about 1 year
old. Harry received a mixture of institutional care and foster care before
he was adopted. His adoptive parents, Mr. and Mrs. Johnson, reported
that when he was adopted, he was unable to crawl or walk and had diffi-
culty sitting by himself. The pediatrician reported that Harry was small
for his age and malnourished.
When Harry was 15 months old, he was evaluated by an early edu-
cation program and qualified for physical and speech/language ther-
apies. Harry’s motor skills progressed rapidly and within one year’s
time, he no longer demonstrated motor delays. The speech-language
pathologist (SLP) noted rapid progress in receptive language and in-
telligibility, but his expressive language remained delayed particularly
in discourse. Although his parents said Harry played with his brother,
the two boys seemed to play beside each other and not converse. Harry
became inconsolable when they could not understand what he wanted.
Eventually Harry became passive and quiet. When Harry was enrolled
in a preschool, he showed regressive behaviors (separation anxiety, re-
duced eye gaze, solitary play, discomfort with negative emotions dis-
played by other children, aggressive behaviors) at which time Mr. and
Mrs.  Johnson sought services from an international adoption clinic.
The clinical psychologist observed that the parents seemed tense and
uncomfortable with each other when interacting with Harry. Mr. John-
son demonstrated an authoritarian interaction style, and Mrs. Johnson
and Harry responded passively by withdrawing. The SLP conducted a
play assessment and observed that when playing with dolls pretend-
ing to cry, Harry crawled under the table, covered his ears, and closed
his eyes.
The psychologist and SLP suspected that Harry demonstrated symp-
toms of reactive attachment disorder with secondary developmental
delays associated with institutional care or neglectful foster care. Harry
had learned to cope with negative events by withdrawing or crying, and
these coping behaviors were ineffective at home and school. The parents
had difficulty reading Harry’s cues and interpreting his communica-
tion, and the authoritarian parenting style was not a positive match for
Harry’s emotional needs. Harry needed to develop a secure relation-
ship with both parents as a foundation of security to enable independent
emotion regulation at home and preschool as well as communication of
wants, needs, and feelings. Mr. and Mrs. Johnson needed to learn how
to read Harry’s cues to improve their sensitivity, attunement, and at-
tachment with Harry as well as parenting strategies to develop positive
ways to interact with Harry. Harry continued to qualify and need early
 Children Exposed to Maltreatment • 289

childhood special education, family counseling, and speech-language

services to improve his attachment, play development, emotion regula-
tion, expressive language, and socially functional communication.
Harry’s case represents the complex needs of children who have
experienced maltreatment, for example, neglect and/or abuse. Harry
demonstrated developmental delays in relationship development, emo-
tion regulation, expression of emotional themes or emotional com-
munication, general communication, and social and play behaviors.
Although Harry was removed from an environment of neglect and pos-
sibly abuse, he needed special, individualized support for his unique
developmental profile. His parents also needed support to understand
Harry’s emotional needs and how best to support his development.
This case description supports Dynamic Systems Theory in that prea-
doption and post-adoption environmental factors interfaced with indi-
vidual variables, which resulted in varied and complex developmental
outcomes.

INCIDENCE, PREVALENCE, AND DEFINITIONS

There are many different types of abuse and/or neglect. According to the
US Department of Health and Human Services (2012), define physical
abuse and neglect as

any recent act or failure to act on the part of a parent or caretaker

which results in death, serious physical or emotional harm, sexual
abuse or exploitation; or an act or failure to act, which presents an
imminent risk of serious harm. (p. vii, italics in original)

Abuse can include physical, sexual, or psychological abuse. Neglect con-

stitutes failure of a caregiver to provide shelter, supervision, medical or
mental health treatment, educational and/or emotional needs. Of the
different types of maltreatment, neglect was the most commonly re-
ported form of abuse. During 2012, the US Child Protective Services
responded to 3,184,000 abuse or neglect reports of abuse or neglect, of
which 78.3% were reports of child neglect (Children’s Bureau, 2012).
Maltreatment such as abuse and/or neglect is widespread and a
world-wide problem. The United Nations 61st General Assembly on the
Rights of the Child defined maltreatment as any kind of physical or men-
tal violence, injury or abuse, neglect, exploitation, or sexual abuse (Pin-
heiro, 2006). Pinheiro (2006) reported that data were collected from 131
governments and convened nine regional consultations across the Carib-
bean, South Asia, West and Central Africa, Latin and North America, East
290 • Hwa-Froelich

Asia and the Pacific, the Middle East, Europe, Central Asia, and North,
Eastern, and Southern Africa. He reported that while maltreatment of
children varies across cultures and physical environments, most child
maltreatment is hidden and unreported. In spite of the hidden nature of
maltreatment, World Health Organization (WHO) estimated that:
• 150  million girls and 73  million boys had experienced sexual
abuse;
• between 100 and 140 million girls and women had experienced
genital mutilation or cutting;
• 80% to 98% of children who received physical punishment ex-
perienced it in their homes;
• 20% to 65% of school-age children reported being verbally or
physically bullied;
• 133 to 275 million children witness domestic violence in their
homes; and
• children with disabilities, ethnic minority children, refugees,
and homeless or displaced children are at increased risk (Pin-
heiro, 2006).
Countries track child abuse and neglect in different ways, resulting in
varied incidence and prevalence reports. In spite of this variation, child
maltreatment appears to be on the rise. Recent prevalence studies in
Western nations show an increase in substantiated and reported cases
of abuse and neglect (Australian Institute of Family Studies, 2013; Na-
tional Society for the Prevention of Childhood Cruelty [NSPCC], 2013;
Public Health Agency of Canada, 2008). Although in 2012 the United
States reported a decrease in abuse and neglect cases from 2008, the
prevalence was still high at 686,000 cases (Children’s Bureau, 2012; US
Department of Health and Human Services, 2012).
According to the Diagnostic and Statistical Manual of Mental Disor-
ders (5th ed.; DSM-V; American Psychiatric Association [APA], 2013),
the varied types, duration, and frequency of maltreatment can result
in a range of disorders. These include (a) Reactive Attachment Disor-
der, (b) Disinhibited Social Engagement, (c) Acute Stress Disorder, (d)
Post-traumatic Stress Disorder, (e) Adjustment Disorders or (f) Trauma-
or Stress-Related Disorder not otherwise specified. Reactive attachment
disorder is diagnosed when a child demonstrates socially withdrawn/
inhibited behaviors. When children exhibit disorganized attachment or
indiscriminate friendly or disinhibited social behaviors, they may have
a Reactive Attachment or Disinhibited Social engagement disorder.
Acute stress disorder is used to identify individuals demonstrating stress
behaviors 2 to 4 weeks following a traumatic event. These behaviors may
 Children Exposed to Maltreatment • 291

or may not predict a post-traumatic stress disorder diagnosis. The dif-

ference between acute and post-traumatic stress disorders is the dura-
tion of symptoms and their connection to disassociation. Post-traumatic
stress disorder involves one or a combination of four clusters of behav-
iors: (a) reexperiencing the event, (b) avoidance of negative thoughts or
memories of the event, (c) persistent negative alterations in cognition
or mood such as estrangement from others or excessive blame toward
others, and (d) heightened arousal and reactivity (for specific detail re-
fer to the DSM-5; APA, 2013). An Adjustment disorder is a subtype of
stress disorders in which individuals may demonstrate a wide array of
stress-related behaviors rather than a specific behavioral pattern de-
scribed earlier. The category of Trauma- or Stress-Related Disorders not
otherwise specified is a diagnosis for persons who exhibit some of these
symptoms but not enough or severe enough to qualify under the disor-
ders described earlier (APA, 2013).

LANGUAGE AND SOCIAL COMMUNICATION

DEVELOPMENT OF CHILDREN EXPOSED TO
MALTREATMENT
Educators and medical professionals are likely to encounter children
who have experienced some type of maltreatment (Hwa-Froelich,
2012a). One reason is that children with disabilities are at risk of expe-
riencing maltreatment and may not have the communication abilities
to report the abuse. Second, children who have experienced some form
of maltreatment are at risk of developmental cognitive, language, and
social-emotional delays (Hwa-Froelich, 2012a; Snow, 2009). For exam-
ple, children exposed to neglect demonstrate more frustration, anger
and less flexibility when solving problems, have lower school achieve-
ment and IQ scores, are less securely attached, and have negative inter-
nal models of themselves and others (Allen & Oliver, 1982; for a review
see Hildeyard & Wolfe, 2002; Van der Kolk & Fisler, 1994).
Maltreatment is associated with nonverbal, verbal, and social com-
munication delays (Culp et al., 1991; McFadyen & Kitson, 1996). In a re-
view of the literature, Schore (2001) found that early adverse care often
resulted in poorer social information processing of facial expressions,
tone of voice, and recognition of emotions and perspectives of others
(Camras et al. 1990; Schore, 2001). In addition, children experiencing
maltreatment have poorer communication development (Allen & Oliver,
1982) in syntax, expressive vocabulary, and communicative functions
than a control group matched by socioeconomic status (SES)
292 • Hwa-Froelich

(Coster, Gertsen, Beeghly,  & Cicchetti, 1989). These communication

delays appear to persist into adolescence. For example, 20 adolescents
who had experienced maltreatment during their childhood continued
to demonstrate poorer syntax and social communication skills when
compared with a control group (McFadyen & Kitson, 1996).
Neglect, as opposed to abuse, appears to have more negative ef-
fects on language development (Law  & Conway, 1992; Scarborough,
Lloyd,  & Barth, 2009). Studies including toddlers, preschool-age, and
school-age children who were exposed to abuse, neglect, or abuse and
neglect compared the children’s language performance with a control
group matched by SES. Regardless of age, children exposed primarily
to neglect performed the lowest on all language measures (Coster et al.,
1989; Culp et al., 1991; Fox, Long, & Langlois, 1988). Thus, exposure to
neglect places children at increased risk of language delay.

Language and Social Communication Development

in Children Remaining with Families
Mothers who mistreat their children may have negative perceptions of
their children and interact with them in negative ways (S. R. Wilson,
1999). The communication style of 19 caregivers who were abusive and/
or neglectful toward their children differed from the communication
style of 14 caregivers who were not abusive or neglectful (Eigsti & Cic-
chetti, 2004). The mothers of a maltreated group of children expressed
fewer complex utterances, more commands, and did not adjust their
language according to their children’s age. In contrast, the mothers
who did not mistreat their children produced more age-appropriate
utterances (more expansions and repetitions with younger children)
and more multi-clause utterances and wh-questions. These complex
utterances and questions correlated with their children’s use of auxil-
iary verbs and receptive and expressive language scores. They also used
fewer commands that were related to their children’s higher receptive
vocabulary scores. In other words, mothers who neglect and abuse their
children communicate fewer complex and age-appropriate utterances
adjusted for their child’s individual needs. These communication style
differences may account for the language delays reported in children
exposed to maltreatment and may place these children at risk of poor
social communication development.
Social understanding and communication development are depend-
ent on sensitive and attuned caregiver communicative interactions,
dialogue about the child’s mental states and emotions, as well as conver-
sations about other people’s mental states, emotions, and perspectives
(Baron-Cohen, 1997). Some research has reported that children
 Children Exposed to Maltreatment • 293

exposed to maltreatment demonstrate poorer symbolic play (for a re-

view see Cicchetti & Beeghly, 1987), social or pragmatic language (Man-
so, Garcia-Baamonde, Alonso, & Barona, 2010) and illogical thinking or
thought disorder (Toth, Stronach, Rogosch, Caplan, & Cicchetti, 2011).
For example, Beeghly and Cicchetti (1994) reported that 20 toddlers
who were exposed to maltreatment expressed fewer internal state words
(want, hurt) and word types when compared to 20 toddlers in a control
group matched by SES. Toddlers who experienced maltreatment and
were insecurely attached were at increased risk. In another study con-
trolling SES background and exposure to maltreatment, 203 three- to
eight-year-old children from low-SES backgrounds and maltreatment
exposure and 315 children not exposed to maltreatment from low- and
middle-SES backgrounds were compared on their performance on
false belief tasks to measure social understanding (Cicchetti, Rogosch,
Maughan, Toth, & Bruce, 2003). Types of abuse included neglect, non-
chronic maltreatment, and chronic maltreatment. Children who had
experienced nonchronic or chronic maltreatment had lower scores on
false belief tasks than the control group and maltreatment predicted so-
cial understanding performance. If maltreatment occurred during the
toddler years, the children had lower performance on false belief tasks
than if maltreatment occurred during infancy. Additionally, the type
of maltreatment had differing effects on false belief task performance.
Children exposed to physical or emotional abuse performed more
poorly on false belief tasks than children who had experienced sexual
abuse or neglect (Cicchetti et al., 2003). In other words, early exposure
to sexual abuse or neglect had less negative effects on social understand-
ing development than later exposure to physical or emotional abuse.
In summary, for children remaining in the care of their biological
caregivers who were the perpetrators of the abuse and/or neglect, the
caregivers’ communication style, timing, and type of maltreatment af-
fect language and social communication development. Maltreatment,
particularly physical or emotional abuse that occurs during the toddler
years has negative effects on social understanding development.

Language and Social Communication Development

in Children in Institutional or Foster Care
Children who spend time in institutional care such as group homes or
orphanages may not receive consistent, contingent, or sensitive social
and communicative experiences to facilitate language or social under-
standing development. It is well documented that orphanages pro-
vide poorer and more neglectful care than foster or adoptive families
because of high child-to-caregiver ratios (The Leiden Conference on the
294 • Hwa-Froelich

Development and Care of Children Without Permanent Parents, 2012;

Tizard, Cooperman, Joseph,  & Tizard, 1972; Tizard  & Joseph, 1970).
Tizard and Joseph (1970) compared 30 children living in institutional
settings in the UK with a gender-matched control group of children
raised by their biological parents from skilled, semiskilled, and unskilled
working-class backgrounds. Children raised by their biological families
demonstrated more friendly behaviors, less separation anxiety, higher
nonverbal and verbal intelligence scores, and more spontaneous lan-
guage with more expressive vocabulary and had been exposed to more
experiences.
Lack of social interaction and experience associated with institu-
tional rearing may also have negative effects on the development of so-
cial understanding. Yagmurlu, Berument, and Celimli (2005) studied
34 children residing in Turkish orphanages in comparison to 76 chil-
dren living with their biological families from low- or middle-SES back-
grounds. Regardless of SES background, the children living with their
families had higher false-belief task performance than did children liv-
ing in orphanages. Thus, residing in institutional environments affects
the development of social understanding especially in understanding
false beliefs.
If communication delays are the result of exposure to poor quality
caregiver–child communicative interactions and the lack of stimulating
social experiences, then if children are removed from these situations of
maltreatment (e.g., abusive and/or neglectful or institutional environ-
ments) and are exposed to improved care, appropriate, and increased
social communicative interactions, do they achieve more positive com-
munication development? The goal of social services has been to re-
move children from abusive and/or neglectful environments and place
them into safer environments, such as foster care with the hope that
these changes would result in positive developmental outcomes.
In 2003, the US Department of Health and Human Services reported
542,000 children were in foster care (Vig, Chinitz, & Shulman, 2005).
The reasons often given for foster care placement included: (a) neglect
(30%–59%), (b) parental incapacity (30%–75%), (c) physical abuse
(9%–25%), (d) abandonment (9%–23%), and (e) sexual abuse (2%–6%;
Vig et  al., 2005). These children are at increased risk of being medi-
cally fragile, prenatally exposed to drugs, having congenital infections,
being born premature, and at risk of having a low birth weight. After
birth, they are at risk of shaken baby syndrome, lead exposure, failure
to thrive, chronic health problems, attachment problems, regulatory
problems, post-traumatic stress disorder, and developmental delays
(Vig et  al., 2005). In addition, in a qualitative study, focus groups of
 Children Exposed to Maltreatment • 295

foster caregivers reported that children exposed to maltreatment had

negative self-perceptions, problems understanding and responding to
emotions, and either lacked social understanding or could not access
social understanding when faced with a stressful situation (Luke & Ban-
nerjee, 2012). In conclusion, children in foster care may have complex
medical and developmental profiles requiring specialized care, as well as
social-emotional problems.
Consistent foster caregivers and fewer transitions among foster car-
egivers positively affect development. The development of 3- to 6-year-
old children with documented maltreatment of neglect, sexual abuse,
physical abuse or emotional abuse, were placed in foster care around
3 years old and after 4 to 5 months of foster care were compared with a
group of children living with their biological families matched by educa-
tion and income (Pears & Fisher, 2005). If they had experienced more
transitions in foster care, they had poorer visual-spatial, cognitive, lan-
guage, and executive functioning. Thus, in spite of removal from ad-
verse care and exposure to 4 to 5 months of safer and more stimulating
environments, the lack of consistent caregivers and early exposure to
neglect or abuse had persistent negative effects on language and other
related skills (visual-spatial skills, language, cognition, and executive
function; Pears & Fisher, 2005). Duration of exposure or timing of im-
proved care exposure may affect developmental outcomes.
Timing effects of placement in foster care were studied in 174 chil-
dren residing in Romanian institutions, children moved from institu-
tions to community foster families, and children born into and raised
by their families (Windsor et  al., 2011). Five groups of children were
randomly selected, placed into community foster care at different ages,
or remained in the institution. These groups were compared at 30 and/
or 42 months of age with a group of Romanian children who had never
experienced institutional or foster care. If children received foster care
prior to 24 months of age (receiving 6–18 months of improved care),
they had significantly better language performance at 30 and 42 months
of age than did children who received foster care later in life, but they re-
mained delayed compared to children who were never institutionalized.
Some studies found that children exposed to maltreatment tend to
have higher rates of special education services and maltreatment type
predicted special education treatment (Kurtz, Gaudin, Wodarski, & How-
ing, 1993; Scarborough & McCrae, 2008). Children exposed to physical
abuse were more likely to be diagnosed with social-emotional distur-
bance, children who were neglected were diagnosed as having cognitive
delays, and males and children from culturally or linguistically diverse
backgrounds were at increased risk (Scarborough & McCrae, 2008).
296 • Hwa-Froelich

International Adoption and Disrupted Language and Social

Communication Development
Children who are adopted from different countries may be exposed to
large variances in care, language exposure, and social interaction before
they are adopted; that is, some experience only institutional care, some
experience a mix of relative or foster care and institutional care, and
some experience mostly foster care (Hellerstedt et al., 2008). However,
their exposure to their birth language may be reduced, inconsistent, or
developmentally inappropriate and similar to children living in neglect-
ful environments (The Leiden Conference on the Development and
Care of Children without Permanent Parents, 2012; Tizard  & Joseph,
1970; Windsor et al., 2011). In fact, longer durations of exposure to this
type of care are predictive of poorer developmental outcomes includ-
ing poorer language development compared to children domestically
adopted and children living with their biological families (Cohen,
Lojkasek, Zadeh, Pugliese,  & Kiefer, 2008; Glennen  & Masters, 2002;
Roberts et al., 2005; Tan & Yang, 2005).
In the case of international adoption, children are often adopted by
families who do not speak their children’s birth language. Thus, they
experience a disruption in first language acquisition and begin to learn
a second first language (for a review see Hwa-Froelich, 2009, 2012b).
Does exposure to neglect and disrupted language acquisition adversely
influence language development in spite of receiving consistent im-
proved care after adoption into families from a higher SES background?
In general, children adopted from abroad acquire a second first
language quickly and perform within normal limits on standardized
general language measures (Glennen, 2007; Hwa-Froelich  & Matsuo,
2010; Roberts, et  al., 2005; Scott, Pollock, Roberts,  & Krakow, 2013;
Scott, Roberts,  & Glennen, 2011; Scott, Roberts,  & Krakow, 2008).
When compared to children matched by socioecomonic status and
age, however, they perform less well, and as they reach school age, the
gap widens between children adopted internationally and their peers
(Delcenserie  & Gensee, 2013; Gauthier  & Genesee, 2011; Scott et  al.,
2011). In a meta-analysis, Scott and colleagues (2011) found that al-
though language outcomes were not different from nonadopted peers at
younger ages, children adopted internationally had significantly poorer
language performance than their nonadopted peers during school-age.
For example, children adopted from China demonstrated poorer lan-
guage performance when compared to nonadopted peers (Cohen et al.,
2008; Gauthier  & Genesee, 2011). The reasons for poorer language
performance are unknown, and the variables range from duration of
 Children Exposed to Maltreatment • 297

institutional care (Cohen et  al., 2008; Croft, et  al., 2007; Glennen  &
Masters, 2002; Roberts et al., 2005; Tan & Yang, 2005), disrupted lan-
guage acquisition (Gindis, 2005), or language learning ability as meas-
ured by the age children said their first word in their adopted language
(Gauthier  & Genesee, 2011). It is also possible that children adopted
internationally may demonstrate poorer language performance when
compared to an SES-matched peer group but perform within normal
limits compared to a population-based sample. Because adoptive fami-
lies are largely from a higher SES background (Hellerstedt et al., 2008)
a comparison peer sample may represent scores one to two standard
deviations above the mean on standardized measures. Thus, it may
be more appropriate to determine whether weaker performance of
a child who is internationally adopted is affecting academic or social
participation before referring them for assessment and/or intervention
services.
Neurobiological structure and function, processing and interpreta-
tion of social communication differences have been reported for chil-
dren adopted internationally (for a review see Hwa-Froelich, 2012d).
Children who experienced Romanian institutional care displayed dif-
ferent electrophysiological patterns in response to pictures of facial ex-
pressions and pictures of familiar and unfamiliar persons compared to
children who had experienced Romanian foster care and nonadopted
children (Moulson, Fox, Zeanah, & Nelson, 2009; Parker, Nelson, & the
Bucharest Early Intervention Project Core Group, 2005, 2008).
Children adopted internationally are at risk of social language and
social understanding delays. Glennen and Bright (2005) conducted a
survey study of 46 children adopted from Eastern Europe who were be-
tween 6.6 and 9.1 years of age using two parent-report measures focused
on children’s communication and social skills:

The children scored below the test average for subtests measuring
social relations (e.g., They may seem distant or may unintention-
ally hurt peers), use of context (e.g., They tended to misunderstand
jokes or were too literal), and nonverbal communication (e.g., They
tended to demonstrate poor eye contact or failed to read conversa-
tional overtures). (p. 49; Hwa-Froelich, 2012a)

In other words, children adopted from Eastern Europe may have dif-
ficulty with social communication and delayed social understanding
development. My colleagues and I have also found differences in iden-
tifying emotions from facial expressions in 4-year-old children adopted
from Asian and Eastern European countries before the age of 2 years
298 • Hwa-Froelich

compared with a group of nonadopted children matched by age and SES

background (Hwa-Froelich, Matsuo, & Becker, in press).
False belief development was measured in 120 six- and seven-year-
old children adopted before 3 years old from different countries (Tarullo,
Bruce, & Gunnar, 2007). The children were compared across three groups:
(a) an institutionalized group who had spent most of their preadoptive
lives (10–36 months) in an institution, (b) an age- and gender-matched
group who had received mostly foster care (0–2 months institutionalized)
prior to adoption, and (c) a US nonadopted group of children. Tarullo
and colleagues (2007) controlled for language performance and found
that the institutionalized group’s false-belief task performance was signif-
icantly lower than the other two groups, with the foster care group scor-
ing between the institutionalized and nonadopted groups. These delays
in social understanding development may continue into school age. In a
longitudinal comparison study of 165 Romanian adoptees and children
adopted within the UK (Colvert et  al., 2008), social understanding of
false belief was measured when the children were approximately 11 years
old. The group of Romanian children who were adopted after 6 months
of age demonstrated persistent delays in social understanding develop-
ment. Thus, exposure to institutional care past 6 months of age appears
to have long-lasting effects on later social understanding development.
To summarize, children adopted internationally are at risk for neu-
rological structure and function differences that may affect their social
communication abilities. As exemplified by Harry, these children may
also demonstrate problems interpreting nonverbal communication and
social interactions in different social contexts, as well as understand-
ing social and emotional information. The following section describes
guidelines for assessment and referral.

MEDICAL AND EDUCATIONAL ASSESSMENT

AND REFERRAL GUIDELINES
For us, as professionals working with children, it is important to be
observant of possible signs of abuse and neglect and to be persistent
reporters of maltreatment. Because of the nature of child abuse and
neglect, professionals cannot depend upon caregivers to seek early
childhood screenings or assessment. Consequently, many children
who demonstrate delayed development from these environments are
not identified early and do not receive early intervention services when
needed (Dicker & Gordon, 2006). Family system risk factors of abuse
 Children Exposed to Maltreatment • 299

and neglect include (a) parents with a history of abuse and neglect, who
are socially isolated, and/or who appear to dislike the child or the par-
enting role and (b) children who were born premature, have physical
or mental disabilities, or negative behaviors. Environmental risk factors
include poverty; few social support resources and living in a culture
that condones physical violence or physical discipline (Scannapieco &
Connell-Carrick, 2002). Professionals should enlist the support of their
school or medical team which may include a medical doctor, a nurse, a
social worker, a school counselor, a psychologist, or a psychiatrist who
are mandated reporters of child abuse and/or neglect and are trained in
detecting and documenting physical and behavioral signs of abuse or
neglect as well as verbal disclosures of maltreatment (Snow, 2009).
A three-tiered approach of prevention, reporting and stopping mal-
treatment, as well as assessment/intervention services, is recommended
(Hyter, Atchison, Henry, Sloane,  & Black-Pond, 2001; Scannapieco  &
Connell-Carrick, 2002; Snow, 2009; Trocmé & Caunce, 1998). Parents
and professionals should receive information and training on the types
of parent behavior and child experiences that constitute abuse and ne-
glect. Professionals also need a list of procedures and contact infor-
mation to report maltreatment to Child Protective Services or Social
Rehabilitative Services in the United States. Potential signs of abuse or
neglect can be found on the Child Welfare Information Gateway under
Identification of Child Abuse and Neglect (www.childwelfare.gov/can/
identifying/) which lists possible behaviors or signs. Table  10.1 sum-
marizes these signs. Anyone in the US can contact Childhelp anony-
mously (Childhelp National Child Abuse Hotline 1.800.4.A.CHILD or
1.800.422.4453), which is staffed 24  hours a day, 7 days a week, with
professional crisis counselors with accessibility to a database of 55,000
emergency, social service, and support resources (other contacts include
the Office for Children, Youth, and Family Support in Australia; Chil-
dren’s Aid Societies in Canada; Gateway Services Teams for Children’s
Social Work at the Health and Social Care [HSC] Trust, or the NSPCC
in the United States). Even if no action is taken on initial reports, it is
important to continue to observe and report future incidences to build a
case of chronic abuse and/or neglect that may lead to more positive out-
comes for the child. Multiple observations by different observers help
to provide evidence and support that maltreatment occurred to build
a strong case for government intervention or removal of the child from
the maltreating environment. Once notification has been completed,
assessment and intervention should be completed to insure the child’s
social-emotional and educational needs are met.
300 • Hwa-Froelich

TABLE 10.1 Possible Signs of Child Abuse and Neglect

Child Behaviors Parent Behaviors Child/Parent Behaviors

Sudden changes in behav- Shows little concern for Rarely touch or look at
ior or performance child each other
Physical or medical prob- Denies presence of or View their relationship as
lems reported to parents blames child for child’s negative
not addressed problems in school or at
home
Learning or attention Views child as bad, worth- State they do not like each
problems not caused by less, or burdensome other
physical or psychological
problems
Hypervigilent Asks others to use harsh
physical discipline if child
misbehaves
Lacks adult supervision Demands physical/aca-
demic performance above
child’s abilities
Overly compliant, passive, Depends on the child for
or withdrawn care, attention, and satis-
faction of emotional needs
Comes to school or other
events early, stays late, does
not want to go home

Note: Adapted from Johnson (2012) and Child Welfare Information Gateway (2007).

Assessment Practice
Children who may have experienced abuse, neglect, and/or trauma need
to be assessed by a team of professionals. This team may include pedia-
tricians, school nurses, clinical psychologists, family therapists, social
workers, and legal professionals such as police officers or court-appointed
officials who receive training and education on working with children
exposed to maltreatment or trauma (Horowitz, Owens, & Simms, 2000;
Hyter et al., 2001). The purpose of this chapter is to focus on the role of
the SLP as a member of this team.
Children exposed to maltreatment and children living in foster care
have complex developmental profiles requiring individualized assess-
ments that are ongoing (Vig et  al., 2005). Hyter and her colleagues
(2001) developed a model of family-centered and transdisciplinary
practices for the Child Trauma Assessment Center at Western Michigan
 Children Exposed to Maltreatment • 301

University located in Kalamazoo, MI. This model supports a Dynam-

ic Systems Theoretical approach in that the team recognizes different
environmental contexts and other developmental areas may influence
children’s development. With this understanding, the team frames their
services in family-centered practice using an ethnographic interview
process and assessing the child in a transdisciplinary manner.
As previously discussed, children exposed to maltreatment are at
risk of language and social communication delays as well as delays
in executive function and working memory (Delcenserie, Genesee, &
Gauthier, 2012; Desmarais, Roeber, Smith,  & Pollak, 2012; Eigsti,
Weitzman, Schuh, De Marchena, & Casey, 2011; Pears & Fisher, 2005).
For this reason, it is recommended that if children have a history of
maltreatment and are struggling in school, they receive a thorough
speech-language assessment including (a) general language measures,
(b) nonverbal and verbal comprehension and expression of social
cognition (reading facial expressions and tone of voice, social under-
standing, and pragmatics), (c) verbal and visual working memory, and
(d) executive function. Measures of working memory and executive
function are described by Dr. Westby in Chapter 2 and Dr. Timler in
Chapter 9. Assessments for children exposed to maltreatment will fo-
cus on general language measures that include a subtest of pragmatic
or social communication skills or measures that focus on pragmatic
language or social understanding.
Because research has documented that exposure to maltreatment
may impact multiple developmental areas including language and so-
cial communication, a comprehensive assessment is needed that takes
into consideration culturally and age-appropriate methods (Horowitz
et  al., 2000; Hyter et  al., 2001). Using an ethnographic interview to
gather pertinent and valuable information regarding the child’s mal-
treatment history, cultural and linguistic differences, and the biological,
foster, or adoptive parents’ observations will assist all professionals in
preparation for the assessment (Westby, Burda, & Mehta, 2003). Gath-
ering authentic or portfolio measures of language-based school per-
formance (language, writing, and spelling samples; achievement test
scores) and teacher observations and measures may assist SLPs in de-
termining other language areas that may be affected by maltreatment.
For children who have experienced maltreatment and speak English
as their primary language, mainstream, English-standardized assess-
ments are appropriate. Please refer to Table 10.2 for a list of measures
reported in the literature that have been used with children experienc-
ing maltreatment.
TABLE 10.2 Measures of Social Communication in Children Exposed to Maltreatment
General Social Communica- Age Range Purpose Research Studies
tion Measures
Communication and 1–2 years Norm-referenced play-based measure of Glennen (2007);
Symbolic Behavior communication, social and symbolic behav- Hwa-Froelich & Matsuo (2010)
Scales–Developmental Profile iors
(CSBS-DP; Wetherby & Pri-
zant, 2002)
Transdisciplinary Play-Based 1 month to Play-based arena assessment across develop- Daunhauer, Coster,
Assessment, Second Edition 6 years mental domains Tickle-Degnen, & Cernak
(TPBA2; Linder, 2008) or rat- (2010); Hwa-Froelich, (2012c);
ings of play behavior Kreppner, O’Connor, Dunn,
Andersen-Wood, and the Eng-
lish and Romanian Adoptees
(ERA) Study Team (1999)
Language Sample 30–33 months Child and mother conversational analysis Coster et al. (1989)
of communicative functions, decontextu-
alization, conversational relatedness, and
relevance
Social Communication
Research Tasks
Stories about emotions, emo- 3–7 years Stories about emotions created by research- Camras et al. (1990); Camras,
tional facial expressions ers, photos, or drawings of facial expressions Perlman, Wismer Fries, & Pol-
lak (2006); Tarullo et al. (2007)
The Diagnostic Analysis 3–99 years Error scores are compared to means and Colvert et al., 2008;
of Nonverbal Accuracy–2, standard deviations for each age group. Hwa-Froelich, Matsuo, &
(DANVA2; Nowicki & Duke, Becker (in press)
1994)
Theory of Mind tasks 4–6 years Research tasks: Unexpected contents task Ciccheti et al. (2003); Tarullo
(Perner, Frith, Leslie, & Leekman, 1989), et al. (2007); Yagmurlu et al.
Sally-Anne false-belief story (Wimmer & (2005)
Perner, 1983), explaining action task
(Bartsch & Wellman, 1989). Children are
expected to 2 questions measuring inter- or
intra-ToM for each of the 3 tasks and receive
a score of at least 5/6.
Strange Stories (Happé, 1994) 5–12 years Research tasks of stories depicting social Colvert et al. (2008)
interactions, jokes, sayings, and false beliefs.
Scores are compared to means and standard
deviations.
Caregiver–Child Social/Emo- 0–8 years Rating scale for observations of parent–child McCall, Groark, & Fish (2010)
tional and Relationship Rating interaction
Scale
Parent Report Measures
Ages and Stages Questionnaire 1–66 months A screening parent-report questionnaire Walsh & Viana (2012); S. L.
(Squires & Bricker, 2009) covering gross and fine motor development, Wilson & Weaver (2009)
problem solving, and social skills.
Children’s Communication 4:0-16:11 years Norm-referenced parent report measure of Glennen & Bright (2005);
Checklist–2 (CCC-2; Bishop, child communication behaviors Sadiq et al. (2012)
2003)
304 • Hwa-Froelich

Transdisciplinary and ecological assessments are considered best practice

when working with young children and their families (Horowitz et al.,
2000; Hyter et al., 2001; Paul & Norbury, 2012). For prelinguistic children,
parent-report instruments and play-based assessment strategies including
parents and siblings are recommended. Observation, mediation and facil-
itation of play behaviors can help the practitioner assess social-emotional
development (expression of emotions, emotion and behavior regulation,
sense of self, and social interactions), cognitive development (attention,
memory, problem solving, social cognition), communication develop-
ment (comprehension, expression, pragmatics, articulation), and mo-
tor development (Linder, 2008). It also allows family members to par-
ticipate so interactions among the family members can be observed. The
Communication and Symbolic Behavior Scale–Developmental Profile
(Wetherby & Prizant, 2002) is a standardized test that measures social,
communication and symbolic behaviors of children between the ages
of 12 and 24 months. Although play-based assessments continue to be
appropriate and recommended for preschool-age children, additional
standardized measures are available. After the age of 2, some executive
function and selective attention tasks may be administered. Once the
child is 4 years old, one can assess nonverbal communication, social un-
derstanding, and phonological short-term memory.
For school-age children, formal and informal evidence-based assess-
ments may be used. In all cases, it is recommended to assess receptive
and expressive language, pragmatic language, social understanding,
short-term and working verbal and visuo-spatial memory, attention
(joint and selective), and executive function. Because attention and
memory skills may also be influenced by processing speed or auditory
processing skills, the SLP should consider assessing these skills. Expres-
sive language delays may not be apparent on general language measures
but may affect higher order language skills such as inferential language,
narrative language, and reading comprehension, thus these areas may
need to be assessed also.
In the case of Harry, a transdisciplinary play-based assessment was
performed (Linder, 2008). The SLP and the counselor conducted an
ethnographic interview with the parents to gather information about
previous assessments and interventions. As a team, they administered a
general speech and language assessment and a play-based arena assess-
ment in collaboration with the Occupational and Physical Therapists.
The parents were asked to complete the Children’s Communication
Checklist–2 (Bishop, 2003).
The results of the assessment indicated developmental delays in ex-
pressive and pragmatic language, nonverbal communication, and fine
 Children Exposed to Maltreatment • 305

motor skills. During the play assessment, Harry demonstrated delays

in emotion regulation, attachment, attention, and persistence during
problem solving, and reduced complexity in symbolic play. For exam-
ple, Harry hid when dolls pretended to cry and he did not seek comfort,
emotional connection, or joint attention with either parent or siblings.
Although Harry qualified for special education services, the early inter-
vention team recommended that Harry receive additional assessment in
selective attention, phonological short-term memory, and social under-
standing or false-belief tasks. The results of these additional assessments
indicated that Harry had adequate short-term phonological processing
but was not able to express his own mental actions or the thoughts of
others, and had difficulty regulating his attention and emotions when ex-
periencing stressful events. Thus, a speech/language intervention using
a relationship development framework to improve comprehension and
expression of emotions, increasing selective attention, executive function,
and expressive and social language were recommended as well as family
therapy with a clinical psychologist with experience with families who
had adopted children from abroad (S. L. Wilson, 2012).

TREATMENT PRACTICES
Children with a history of maltreatment may have difficulty trusting
others and developing close, secure relationships. All professionals,
including SLPs, should work closely with families in developing close
trusting relationships with these children (Heller, Smyke, & Boris, 2002;
Hughes, 2004; Hwa-Froelich, Wilson, Harris, & Ladage, 2012; Vig et al.,
2005). It is also essential that judicial and family service systems work
to reduce transitions in foster care to enable children to have consistent
care to develop trusting relationships (Dicker & Gordon, 2006). A team
treatment approach will ensure a consistent and supportive process to
meet the child’s needs and prevent confusion or conflict among profes-
sionals and the caregivers.

Caregiver and Individual Treatment

A positive social communicative environment is dependent upon the
development of a trusting relationship with caregivers (for a review see
S. L. Wilson, 2012). Young children who have experienced disruption
of relationships, such as having multiple and inconsistent caregivers or
losing contact with consistent foster caregivers, need special attention
devoted to building strong and secure relationships to help them regulate
and cope with their internal negative emotions and external stressors.
306 • Hwa-Froelich

Children use these strong early relationships to develop a framework for

future relationships with others outside of the family, learn to attend to
facial expressions, tone of voice, and emotions, regulate their own emo-
tions, and interpret and respond to others’ communication and emotions
(for a review see Chapters  3, 4, and 5; Barth, Crea, John, Thoburn,  &
Quinton, 2005; Juffer, Bakermans-Kranenburg, & Van IJzendoorn, 2005;
Nickman et al., 2005; Reyes & Lieberman, 2012; Vig et al., 2005).
Most interventions focusing on relationship-based communication
have been developed for children with social communication problems
such as children with Autism Spectrum Disorder (ASD). These inter-
ventions have sufficient evidence of effectiveness and are discussed by
Drs. Fannin and Watson in Chapter 7. These include relationship-based
models such as, joint attention intervention (Kasari, Fannin, & Goods,
2012), and the Early Social Interaction Project (Woods, Wetherby,
Kashinath, & Holland, 2012). Joint attention intervention is a SLP and/
or parent delivered play-based intervention designed to improve overall
joint engagement through improvement of initiated joint attention and
responses to joint attention (Kasari et al., 2012; Kasari, Gulsrud, Wong,
Kwon, & Locke, 2010). The Early Social Interaction Project combines
developmentally appropriate practice and family-centered practice, to
provide naturalistic instruction to improve children’s shared joint at-
tention, intentional, and social communication and to share emotions
in naturalistic environments (Woods et  al., 2012). Although little re-
search evidence on efficacy is available for the Developmental, Individ-
ual Difference, Relationship-Based: Floortime Model (DIR: Floortime;
Greenspan & Wieder, 2006), it is based on similar theoretical models as
joint attention and the Early Social Interaction Project and has emerg-
ing evidence that the treatment approach is effective (Gerber, 2012).
This intervention model focuses on “the functional emotional develop-
mental levels (FEDLs),” which are “shared attention and regulation, en-
gagement and relating, two-way intentional communication, complex
problem-solving, creative representations and elaboration, and repre-
sentational differentiation and emotional thinking” (p. 80).
All of these models support facilitation of primary intersubjectiv-
ity, joint attention, emotion regulation and inhibition, memory and
recall, and social communication, which are skills that would benefit
children who have been exposed to maltreatment and/or disrupted
relationship development. These models are also based on a develop-
mental hierarchy of relationship development that promote social in-
teraction through play-based activities in which participants learn to
communicate and share emotions through positive playful interactions.
They include strategies for sharing emotions face-to-face through both
 Children Exposed to Maltreatment • 307

nonverbal and verbal communicative interactions that can also be adapt-

ed for older children. Once caregivers and children improve their ability
to read and interpret each other’s communication, facilitation of shared
perspectives or joint attention with an inanimate or animate object is
possible. Relationship and communication development are refined
through stages of coordinated interactions, where children learn how
to coordinate their actions and communication with another person.
Once nonverbal and verbal communication skills become more coor-
dinated, dynamic and flexible thinking is facilitated when new or un-
expected events occur, helping children learn how to reflect on their
own and others’ actions. Eventually, practitioners can assist children to
recall and reflect upon events from multiple perspectives. By helping
children achieve and move through stages of relationship development,
practitioners and parents facilitate their children’s attention, inhibition,
memory, and social communication. However, some children may need
additional support in any one of these developmental areas.
SLPs should focus on assisting caregivers’ abilities to accurately read
their children’s communication to support the family’s positive attune-
ment with one another and primary and secondary intersubjectivity. Pri-
mary intersubjectivity can be facilitated by creating and engaging in social
face-to-face games, such as peek-a-boo or holding the child at a distance,
then moving closer and closer to rub noses or plant kisses. In addition to
developing intersubjectivity, treatment could focus on increasing caregiv-
ers’ explicit, contingent responses to their children’s communicative at-
tempts. For example, the caregiver could talk directly to the child and try
to interpret the child’s vocalizations as intentional comments or requests.
Treatment should also include strategies to facilitate caregivers’ increased
expression of different kinds of words and more complex syntax, to im-
prove the quality of caregiver communicative input. As children move
from toddlerhood to preschool age, instruction could include discussions
about mental states and emotions leading to taking perspective of one’s
self and others’ mental states to promote social understanding and so-
cial communication development (Dunn, Brown, Slomkowski, Tesla, &
Youngblade, 1991). SLPs could also provide dynamic practice in associ-
ating facial expressions and vocal tones with emotional states by using
stories or videos of social interactions and by role-playing common social
contexts, such as contexts in which emotions cause people to behavior in
certain ways and when events cause people to experience common emo-
tions. For example, a video could be found or created showing a child is
hurt and starts to cry and the child’s friend tries to console the hurt child.
When working with foster, adoptive, or biological caregivers and
their children, practitioners need to understand some of the obstacles
308 • Hwa-Froelich

that may occur. Juggling all the medical, social, and developmental
needs their child may have following exposure to maltreatment, can
result in organizational overload for the family (Heller et  al., 2002).
They may miss appointments or feel stressed and overloaded with the
amount of extra care their child needs. They may not have taken “psy-
chological ownership” of their child for a variety of reasons (p. 561). It
is important for the child that the parents, regardless of their role, take
full parental responsibility for the care of their child. There are several
factors involved in developing psychological ownership, such as foster
parents creating an emotional distance or not attach to the child so
they can avoid feelings of loss if the child is removed or they may feel
they lack the power to take responsibility because the biological par-
ents may retain the right to make medical decisions for the child even
when the child does not live with them. The foster caregivers may not
have the necessary knowledge or understanding of the child’s behav-
ioral and developmental needs (Heller et al., 2002). Similar to foster
parents, adoptive or biological parents (if the child returns to biologi-
cal parents who were the source of the maltreatment) may not fully
accept the child as a member of their family or may resist forming an
attachment for fear that the child may eventually be removed from
their care. All families with children exposed to maltreatment need
support and assistance in providing adequate medical, social, and de-
velopmental care for their children and in developing close, positive
relationships.

School-Based Treatment Programs

Only one study using a school mentoring program for children expe-
riencing maltreatment could be found. In this study, 615 children and
youths were followed for an average of 21 months (Mallett, 2012). Each
child was matched according to individual needs with a certified teacher
who served as the child’s mentor and met with the child between 1 to
4 hours per week for the duration of the program. After 1 year in the
program, the children improved twice as fast as the national norms
and after approximately 2 years in the program the children caught up
with test norms for intellectual and cognitive abilities, scholastic apti-
tude, oral language, and overall academic achievement. These rapid
gains slowed down by the third year. This study provides preliminary
evidence that children who have experienced maltreatment can suc-
ceed academically when they receive individualized mentoring. Other
studies with children from at-risk backgrounds have also found that
children need supportive social relationships to succeed in school
(Snow, Porche, Tabors, & Ross-Harris, 2007).
 Children Exposed to Maltreatment • 309

CASE STUDY OUTCOMES

In the case of Harry, the psychologist modeled turn-taking games with
Harry and coached the parents as each one learned how to engage Harry
in play and take turns during face-to-face games. She modeled exagger-
ated facial expressions paired with a positive tone of voice to help the
parents express exaggerated positive nonverbal behaviors. Harry began
to associate and interpret these behaviors with positive interactions. In
time, his father learned to change his communicative interactions from
giving directions and threats to commenting on Harry’s actions, talking
about his own actions, and offering choices to help Harry communicate
desires, intentions, and goals. As the relationship between Harry and his
parents improved, the family began to relax and enjoy each other more
during family interactions.
The SLP coached Harry’s parents while they played with Harry to
help ease them into engaging in child-directed play and language stimu-
lation, modeling how to follow Harry’s lead and interests during play
as well as how to comment and talk about both Harry’s actions and
her own. She used storybooks in which the characters were depicted
with different facial expressions to teach and demonstrate emotion
with exaggerated tone of voice while mirroring the characters’ facial
expressions. With consultation from the clinical psychologist and SLP,
the early childhood educators at Harry’s preschool also began to imple-
ment relationship-based intervention and facilitated Harry’s play devel-
opment for higher levels of symbolic play around positive emotional
themes, and attention and emotion regulation during problem solving
or frustrating, challenging events. Gradually, Harry began to have less
anxiety when his parents took him to preschool. He began to demon-
strate positive emotional themes during his play and had fewer tantrums
or physical aggression during stressful events. While his play continued
to be less complex than his peers’ play behaviors and he avoided others
when they displayed negative emotions, his play and emotion regula-
tion skills continued to improve over time.
In summary, as professionals, our assessment and intervention
approaches with children exposed to maltreatment should be com-
prehensive. All professionals should work toward preventing child
maltreatment. Once maltreatment has occurred, however, the children
and their families should receive a comprehensive, ecological assess-
ment and preventative measures should be implemented to avoid con-
tinued exposure to maltreatment. Our interventions should include the
participants and contexts in which children live to build safe and secure
positive relationships.
310 • Hwa-Froelich

DISCUSSION QUESTIONS
1. What are the reasons you think neglect tends to be more debili-
tating than physical or sexual abuse?
2. What are the developmental outcomes for children who have
been exposed to maltreatment?
3. What are the reasons you think that these outcomes are similar
for children who are removed from maltreatment and are cared
for in foster families or are adopted?
4. Describe the three-tiered approach for preventing child abuse
and neglect.
5. Describe the types of assessment that may need to be considered
for children exposed to maltreatment.
6. Describe the kinds of interventions that may be needed for chil-
dren exposed to maltreatment. Consider individual, caregiver,
and school programs.

CLINICAL RESOURCES
Centers for Disease Control website: www.cdc.gov/violenceprevention/childmal
treatment/
Child Help website: www.childhelp-usa.org/pages/statistics
Children’s Bureau website: www.acf.hhs.gov/programs/cb/research-data-
technology/statistics-research
Child Trauma Academy: www.childtrauma.org/
Child Trauma Institute: www.childtrauma.com/
Child Welfare Information Gateway: www.childwelfare.gov/can/
National Association of Counsel for Children website: www.naccchildlaw.org/
National Child Traumatic Stress Network: www.nctsn.org/
National Criminal Justice Reference Service: https://www.ncjrs.gov/childabuse/
National Institute of Justice website: www.nij.gov/topics/crime/child-abuse/
welcome.htm
Rebuilding Shattered Lives: An Adoption Story: www.youtube.com/watch?v=
C8b0rYBT85s
The Future of Children website: http://futureofchildren.org/publications/jour
nals/journal_details/index.xml?journalid=71
World Health Organization: www.cdc.gov/violenceprevention/childmaltreat
ment/
Zero to Three website: www.zerotothree.org/maltreatment/child-abuse-neglect/
child-abuse-and-neglect.html
 Children Exposed to Maltreatment • 311

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 11
SOCIAL COMMUNICATION ASSESSMENT AND
INTERVENTION FOR CHILDREN WITH
DISRUPTIVE BEHAVIOR PROBLEMS
Carol E. Westby

Ironically, these disorders are defined mainly by the emotions they stir
up in adults. Can a youth have a “disruptive behavior disorder” without
somebody to disrupt? Does a tree falling in the forest make any sound
if no one is there to hear it fall? Kids are called disruptive and disturbed
when others in their life space feel disrupted and disturbed. . . . Emo-
tional disturbance is not a solo performance but a dance with multiple
partners. No matter who takes the lead, others play supporting roles.
—Brendtro and Shahbazian (2004, pp. 71–72)

LEARNING OBJECTIVES
Readers will
1. Be able to define the criteria for diagnosis of oppositional defi-
ant disorder and conduct disorders.
2. Be able to describe the characteristics of children and adoles-
cents with callous-unemotional, narcissistic, and Machiavellian
traits.
3. Be able to describe the patterns of theory of mind strengths and
deficits in children and adolescents with different behavioral/
attitudinal patterns.
4. Acquire strategies to assess the language skills of children and
adolescents with disruptive behavioral disorders.

320
 Children With Disruptive Behavior • 321

5. Become familiar with some of the intervention programs used with

children and adolescents with disruptive behavioral disorders.
Alec was not in kindergarten long before it was obvious he was hav-
ing a difficult time; he was crying, melting down easily over reasonable
requests, yelling at and pushing other children, and even talking about
dying. He was diagnosed with ADHD and anxiety disorder. Medica-
tions were attempted but were not found to be helpful. Alec presented
as a child with ADHD and oppositional defiant disorder (ODD). In first
grade he had difficulty learning to read. In second grade, he became more
resistant to teachers’ instructions and his negative moods and aggressive
behaviors escalated to the degree that by fourth grade he met the diag-
nostic criteria for conduct disorders (CDs) with callous-unemotional
(CU) traits. For example, he threatened others and picked fights for no
apparent reason, was particularly vicious with his sister, and when he
was caught stealing or lying, he denied the behavior and blamed others.
Alec displayed no concerns for the feelings of others and showed no
guilt or remorse when he hurt others or damaged something.

DIAGNOSTIC CRITERIA FOR DISRUPTIVE

BEHAVIORAL DISORDERS
This chapter will focus on children who meet the criteria for diagno-
sis of ODD or CD, two forms of disruptive behavioral disorder (DBD)
described in the Diagnostic Statistical Manual (5th ed.; DSM-5; Ameri-
can Psychiatric Association [APA], 2013). Note: Schools typically use
the term emotional and behavioral disorder (EBD) rather than DBD,
but EBD is not used in the DSM-5. Schools may or may not use the diag-
nostic criteria associated with ODD and CD when diagnosing students
with EBD to qualify them for special education services.
In the DSM-5, criteria for ODD are grouped into three types: angry/
irritable mood, argumentative/defiant behavior, and vindictiveness,
reflecting that the disorder includes both emotional and behavioral
symptoms (APA, 2013; Buitelaar et  al., 2013). These behavioral and
emotional symptoms are frequent and persistent. They may be confined
to only one context, although in more severe cases the symptoms are
present in multiple settings. Even if individuals show symptoms in only
one context, they typically exhibit significant impairments in their social
functioning. Many children and teens with ODD also have other behav-
ioral problems, such as attention-deficit/hyperactivity disorder, learning
disabilities, mood disorders (such as depression), and anxiety disorders.
322 • Westby

ODD symptoms are often part of general problematic interactions with

others. Persons with ODD do not regard themselves as oppositional and
typically view their anger and argumentative or vindictive behaviors as
justified in the face of what they perceive as unreasonable demands.
Diagnosis of CD in the DSM-5 (APA, 2013) is based on a persis-
tent pattern of behavior in which the basic rights of others or major
age-appropriate norms are violated. Symptoms of CD are divided into
two related but distinct “aggressive” and “rule-breaking” clusters. In
the DSM-5, CD is defined based on the presence of 3 of 15 criteria that
should have been present in the last 12 months, and of which one must
have been present in the past 6 months. These 15 criteria are categorized
into four subtypes: (a) aggression to people and animals, (b) destruction
of property, (c) deceitfulness or theft, and (d) serious violations of rules.
These behaviors are often referred to as antisocial behaviors. Individuals
with CD who display aggressive symptoms frequently misperceive the
intentions of others as more hostile and threatening than is the case. As
a consequence, they maintain that their aggression is reasonable and
justified. They also tend to be thrill seeking and reckless and to have a
generally negative mood, poor frustration tolerance, irritability, temper
outbursts, suspiciousness, and insensitivity to punishment. Aggressive
behaviors such a hitting, pushing, slapping, biting, kicking, and spitting
are universal among young children, but as children grow older, most
learn to inhibit these aggressive behaviors. Children who continue to
manifest aggressive and rule-breaking behaviors may receive a diagno-
sis of CD.
The prevalence of ODD ranges from 1% to 11% with an average prev-
alence estimate of 3.3%. Prevalence rates for conduct disorders range
from 3% to more than 10% with a median of 4%. The prevalence of
ODD and CD appears to be fairly consistent across various countries
that differ in race and ethnicity. These rates are higher among males
than females (ODD, 1.4:1) and rise from childhood to adolescence
(APA, 2013). CD is more common in boys (6%–19%) compared with
girls (2%–9%), the gap narrows in adolescence. Boys tend to be aggres-
sive whereas girls are more likely to break social rules through offenses
such as truancy, lying, and prostitution (Offord, 1987).
ODD indicates risk for early onset of CD (Moffitt et al., 2008). For a
significant number of children who develop CD, ODD often emerges
first, followed by the onset of the more severe CD symptoms (Frick &
Nigg, 2011). In a longitudinal study of children, 71% to 78% of children
who developed CD between the ages of 4 and 9 met criteria for ODD
earlier in development, whereas the rate was only 30% of those who met
criteria for CD after age 10 (Burke, Waldman, & Lahey, 2010). Although
 Children With Disruptive Behavior • 323

there is a strong relationship between ODD and CD, a large percentage

of children with ODD do not have CD, nor do they go on to develop CD
(Maughan, Rowe, Messer, Goodman, & Meltzer, 2004). Similarly, only a
minority of children with CD have a diagnosis of ODD, and the propor-
tion of youths with CD without ODD increases from childhood to ado-
lescence (Burke et al., 2010). Many of the symptoms of ODD and CD
overlap. The behaviors of individuals with ODD are typically less severe
than those of individuals with CD and do not include aggression toward
individuals or animals, destruction of property, or a pattern of theft or
deceit. ODD includes problems with emotional dysregulation that are
not included in the definition of CD. Thus, students can be diagnosed
with both ODD and CD.
The CD diagnosis is subtyped or specified in terms of age of onset
of symptoms—childhood onset (prior to age 10) and adolescent onset
(after age 10). Children with early onset frequently have had ODD dur-
ing early childhood, ADHD, and other neurodevelopmental difficulties,
for example, deficits in executive functioning, cognitive deficits (low
intelligence) and ADHD (with impulsivity and problems in emotional
regulation; Frick  & Viding 2009; Moffitt, 2006). There are significant
differences in life-course trajectories of these two groups. Children in
the early-onset group often begin to show mild conduct problems in
preschool or early elementary school, and their behavioral problems
tend to increase in rate and severity throughout childhood and adoles-
cence. They are more likely to show antisocial and criminal behavior
into adulthood and are at greater risk for later mood disorders, anxi-
ety disorders, posttraumatic stress disorder, impulse control disorders,
and substance-related disorders as adults. By age 18 the majority meet
the criteria for antisocial personality disorder. Although the group rep-
resents a small portion (3%–5%) of the total group with CD, they are
responsible for about half of the criminal offenses committed by young
offenders. Children with early onset CD are also more likely to come
from homes with more conflict, live with parents who use less effec-
tive parenting, and have behaviors with a genetic basis than are those
with adolescence onset. Children with adolescent onset CD are less
likely to have temperamental, cognitive problems, and negative family
factors, and they tend to have lower genetic risks. Their behaviors are
more likely due to negative forms of social learning in their peer groups.
If their difficulties persist into adulthood, they are often due to conse-
quences of their adolescent antisocial behavior, for example, a criminal
record or dropping out of school.
For the CD diagnosis, the DSM-5 (APA, 2013) also includes speci-
fiers for callous and unemotional (CU) traits. These CU traits are part
324 • Westby

of what has been termed the Dark Triad (Paulhus  & Williams, 2002),
three related, socially undesirable personality traits: psychopathy, which
involves callousness, lack of personal affect, and remorselessness; Machi-
avellianism, characterized by manipulation and exploitation of others,
a cynical disregard of morality, and a focus on self-interest; and narcis-
sism, which is a grandiose self-view, a sense of entitlement, egotism, and
a desire to establish dominance over others. Emerging research suggests
that all three components of the dark triad are distinct constructs that are
linked to aggressive behavior in children (Kerig & Stellwagen, 2010) and
adults (Baughman, Dearing, Giammarco,  & Vernon, 2012). The Dark
Triad, particularly Machiavellianism and CU traits, is associated with
aggression, emotional instability, and delinquency in adolescents (Muris,
Meesters, & Timmermans, 2013). Narcissism is associated with bullying
behaviors. There is a strong genetic influence in persons with the Dark
Triad of behaviors and persons with combined CD and the CU traits.
In contrast, in antisocial youth without CU, the environmental influ-
ence is substantial and the genetic influence is small (Viding, Jones, Paul,
Moffitt,  & Plomin, 2008). Children with a callous and unemotional
interpersonal style are at risk for developing the severe and persistent
externalizing problems characteristic of childhood-onset CD. Machi-
avellianism, per se, is not part of the CD criteria, but deceitfulness, as
defined in the criteria, is an aspect of Machiavellianism. Whereas CU
traits are associated with extreme forms of physical violence (Frick, Cor-
nell, et al., 2003; Frick, Kimonis, Dandreaux, & Farell, 2003), Machiavel-
lianism is more often associated with relational aggression and with cov-
ert and sneaky misbehavior (Kerig & Stellwagen, 2010; McIlwain, 2003;
Repacholi, Slaughter, Pritchard,  & Gibbs, 2003). Relational or covert
aggression causes harm by damaging a person’s social status or relation-
ships. The covert aggressive behaviors of Machiavellianism are less likely
to draw negative attention to the perpetrator than the overt aggression of
persons with CU (Kerig & Sink, 2010).
Bullying behavior is one of the criteria for CD. Adolescents high on
CD, narcissism, and CU are more likely to engage in bullying (Fanti &
Kimonis, 2012; Stellwagen  & Kerig, 2013b). Youth and adolescents
high on narcissism have strong feelings of entitlement combined with
willingness to exploit younger or weaker children for their own per-
sonal gain. Bullies use aggression toward peers to achieve their own
desired goals. Regardless of levels of CD and CU, those with CU traits
are likely to engage in more severe and stable bullying (Fanti & Kimo-
nis, 2012). Although adolescents with CU traits and narcissism are at
risk of engaging in bullying, not all individuals who bully are diag-
nosed with CD.
 Children With Disruptive Behavior • 325

DBD, SOCIALEMOTIONAL COMPETENCE,

AND THEORY OF MIND
DBD is frequently associated with abnormalities in social cognition
(Frick & Viding, 2009; McMahan & Frick, 2007). Other forms of atypi-
cal social cognition, such as impaired emotion recognition (Fairchild,
Van Goozen, Calder, Stollery,  & Goodyer, 2009) and poor theory of
mind (ToM; Donno, Parker, Gilmour,  & Skuse, 2010) have also been
implicated in the development of childhood-onset CD. Some evidence
exists that social cognition moderates the development of childhood
conduct problems, by amplifying or attenuating the effects of other risk
factors. For example, in early childhood, low maternal emotional sup-
port is only predictive of increases in aggression in children who have
delayed ToM (Olson, Lopez-Duran, Lunkenheimer, Chang, & Sameroff,
2011). The capacity to understand the subjective states of others (socio-
emotional competence) helps regulate antisocial behavior in typical
development. Mandy and colleagues (Mandy, Skuse, Steer, St.  Bour-
cain,  & Oliver, 2013) proposed that children with ODD who develop
childhood onset CD may have an inferior capacity for understanding
the subjective states of others compared to children with ODD who do
not go on to develop CD. They hypothesize that socio-emotional com-
petence moderates the developmental relationship between ODD and
CD symptoms; ODD symptoms pose the greatest risk for subsequent
CD symptoms in children with poor socio-emotional competence.
The behaviors associated with some aspects of CD are clearly reflec-
tive of deficits in ToM, particularly affective ToM (Baron-Cohen, 2011).
ToM involves the ability to recognize one’s own thoughts and emo-
tions, the thoughts and emotions of others, and respond appropriately
to or empathize with the emotions of others (see Chapter 2 on social
neuroscience). Machiavellianism also has been distinguished from CU
traits by differences in aspects of ToM. Whereas youth with CU traits
demonstrate deficits in both affective empathy ToM (responding with
an appropriate emotion to the emotions of others) and affective cog-
nitive ToM (recognition and identification of specific emotions; Blair,
Colledge,  & Mitchell, 2001; Loney, Frick, Clements, Ellis,  & Kerlin,
2003; Woodworth & Waschbusch, 2008), youth high in Machiavellian-
ism are able to read emotions accurately and display a good understand-
ing of other’s internal states. They use their cognitive ToM (recognizing
mental states and intentions of others) and affective cognitive ToM
for manipulation rather than altruism; they lack the affective empathy
component of ToM (McIlwain, 2003). Some individuals with CU traits
have difficulty with both affective cognitive ToM and affective empathy
326 • Westby

ToM (responding with an appropriate emotion to another’s emotion)

whereas others have cognitive affective ToM but not affective empathy
ToM. Youth high on CU are poor at recognizing others’ distress cues
and fail to experience physiological arousal from these cues. There is
some neurological evidence for these affective ToM deficits. Youth with
CD in combination with CU traits seem to have deficits in processing
signs of fear and distress in others, seem to be less sensitive to punish-
ment and show more fearless or thrill-seeking behavior (Jones, Laurens,
Herba, Barker, & Viding, 2009; Marsh, et al., 2008).
Ringleader bullying is associated with average or better ToM abili-
ties (Stellwagen & Kerig, 2013a; Sutton, Smith, & Swettenham, 1999),
suggesting that social acumen allows bullies to successfully manipulate
victims, recruit followers, and hide their misbehavior. Studies typically
show that bullies have at least average cognitive ToM skills and even
cognitive affective ToM abilities (Gini, 2006; Monks, Smith, & Swetten-
ham, 2003); they are able to identify thoughts and feelings of others.
These competencies may allow them to anticipate others’ thoughts and
actions and therefore to efficaciously manipulate the group processes
underlying the dynamics of bullying. Bullies exhibit deficits in moral
motivation and affective empathy. The emotions of others do not trigger
an empathic response in them, and even though they know what is mor-
ally right or wrong, they did not feel obligated to do the right thing (Gas-
ser & Keller, 2009). Bully-victims (those who are bullied and in response
bully others) generally exhibit deficits in all aspects of ToM—cognitive,
affective cognitive, and affective empathy. Victims of bullies often have
deficits in cognitive and affective cognitive ToM that result in their lack
of understanding in how others perceive them and that limit their abil-
ity to interpret the behaviors and emotions of others.

DBD AND LANGUAGE DISORDERS

An extensive body of literature has described interrelations among lan-
guage, learning, and behavioral problems in school-age children. Children
who exhibit problem behavior tend to have low language proficiency, and
children with low language proficiency tend to exhibit problem behavior
(Benner, Nelson,  & Epstein, 2002). Although children with a range of
maladaptive behavioral profiles are at risk for communication disorders,
low language proficiency is often overlooked in children whose challeng-
ing behavior is highly salient to adults (e.g., Cohen, Davine, Horodezky,
Lipsett,  & Isaacson, 1993; Donahue, Cole,  & Hartas, 1994). Children’s
language deficits often are misperceived as low intelligence, inatten-
tion, noncompliance, or even as deliberate dishonesty, disrespect, and
 Children With Disruptive Behavior • 327

defiance. For children with DBD, undetected language impairment can

have serious consequences. If adults use language that is beyond students’
comprehension, they may inadvertently increase problem behaviors
(Sutherland & Morgan, 2003). With undiagnosed language impairment,
students will be unable to participate effectively in designed interven-
tions. Language deficits limit children’s ability to benefit from instruc-
tion, talk-based therapies, and complex behavior management plans. All
interventions must include consideration of children’s linguistic needs.
A meta-analysis of studies of language deficits in children ages 5 to 13
diagnosed with EBD found a prevalence estimate of previously uniden-
tified language deficits of around 81%, indicating that it is likely that four
out of five children with EBD had at least mild language impairment that
escaped the attention of relevant adults (Hollo, Wehby, & Oliver, 2014).
Nearly half the children across the studies, 47%, had moderate to severe
deficits. Youth offenders (children and adolescents in the juvenile justice
systems) are three times more likely to display language problems than
their nonoffending peers (Sanger, Moore-Brown, Magnusson, Svoboda,
2001). Studies of youth offender populations have reported that 65% to
100% of the youth exhibited language impairments on standardized lan-
guage measures (Bryan, Freer, & Furlong, 2007; Snow & Powell, 2004).
Furthermore, individuals with CD have difficulty with several aspects
of narrative discourse. Juvenile offenders asked to tell stories in response
to six-frame cartoon stimuli produced as many story grammar elements
as nonoffenders, but the plans, direct consequences, and resolutions in
their stories were less complete than those of nonoffenders (Snow  &
Powell, 2005). Wainryb, Komolova, and Florsheim (2010) asked a group
of youth offenders to talk about instances in which they had caused
harm to another person and nonviolent youth to talk about a time when
they did or said something and someone they knew felt hurt by it. The
violent youth reported what happened when and who did what in their
narratives, but unlike nonviolent youth, they did not organize their sto-
ries around goals and the thoughts and feelings of themselves and oth-
ers. The researchers scored each narrative for references to landscape of
action—references to precipitating events, perpetrator’s harmful behav-
iors, victim’s responses, and the incident’s dénouement and references
to landscape of consciousness—references to intentions, emotions,
and other mental states (e.g., beliefs, desires). Landscape of conscious-
ness can be thought of as linguistic coding for ToM. Nearly all nonvio-
lent adolescents included references to their own intentions and other
mental states in their narratives, and about half included references to
their own emotions. By contrast, less than two thirds of the narratives
of violent youth included references to their own intentions or their
own mental states and about one third included references to their own
328 • Westby

emotions. The lack of landscape of consciousness references was even

more marked when talking about others and not themselves—89%
of nonviolent youth but only 10% of violent youth included in their
accounts at least one reference to their victim’s emotions. Similarly, 54%
of nonviolent youth but only 20% of violent youth speculated about
their victim’s mental states.
Noel (2011) reported similar results with incarcerated youth whom
she asked to produce personal narratives in response to prompts such
as “Tell me a story about a time someone asked you to do something
you knew you weren’t supposed to do. Tell me what you were think-
ing and how you solved the problem.” These youth offenders expressed
themselves in poorly organized, syntactically simple sentences using
few dependent clauses to explicitly signal the temporal and causal rela-
tionships within their stories. Of their narratives, 51% did not have a
plot, which would involve a character’s intention to accomplish a goal.
Rather, their stories reflected an action sequence, or they reported oth-
ers’ responses to their identified problems. References to thoughts and
emotions, either their own or others’, were almost nonexistent. These
findings are consistent with research documenting deficits in empathy
and social cognition among juvenile delinquents. Responsive empathy
has been shown to be a stronger predictor of offender/nonoffender status
than self-reported aggression and antisocial attitudes (Robinson, Rob-
erts, Strayer, & Koopman, 2007). This lack of attention to their victims’
emotions is particularly troublesome, given the centrality that these
attributions have for making moral decisions (Wainryb & Brehl, 2006).

ASSESSMENT FOR CHILDREN AND

ADOLESCENTS WITH DBD
Research is showing that there are multiple factors associated with DBD
that vary considerably for each person. To provide the most appropriate
intervention, children and adolescents should receive comprehensive
evaluations that consider individual characteristics and environmental
factors for each person (Matthys & Lochman, 2010). (See the factors to
consider in Box 11.1.) Ideally, a child or school psychologist with expe-
rience with children with DBD should conduct a functional behavior
assessment, documenting the disruptive behaviors, when they occur,
and how they are responded to. Children and adolescents with ODD or
CD are at high risk for having executive function problems that could
contribute to the behavioral problems or to ability to participate in
interventions, so the psychologist should evaluate the student’s execu-
tive functions as well as general intelligence.
 Children With Disruptive Behavior • 329

Box 11.1 Factors to Consider in Assessment

Individual characteristics to be considered:

• Which specific ODD and/or CD criteria are met?
°  Are CU traits present?
°  Are patterns of Machiavellianism or narcissism present?
• Are there possible genetic bases for the DBD?
• Are there comorbid conditions?
°  ADHD
° Language learning disabilities
° Reading/math disabilities
• What ToM abilities are present? Absent?
Environmental factors to be considered:
• Contextual family factors
° Poverty
° Family structure: single parent, others in the home
° Parental psychopathology
° Marital conflict
° Parent–child attachment

• Parenting practices
° Nonresponsive parenting
° Harsh, inconsistent discipline
° Parental warmth
° Lack of parental supervision and monitoring
• Peer factors
° Friendships
° Peer rejection
° Moderators of social rejection
° Child perception of social status
° Deviant peer groups

• Contextual community and school factors

° Neighborhood problems
° School problems
330 • Westby

The classroom teacher should document the student’s present academic

performance, and if the student is not at grade level, the teacher, the
school psychologist, or the diagnostician should evaluate the student’s
reading, math, and working memory abilities. Contextual family fac-
tors (e.g., poverty, parent psychopathology) and parenting practices can
contribute to children’s and adolescents’ behavior difficulties and fami-
lies need to be involved in intervention programs, so a social worker or
school counselor should interview family members. If a student exhibits
motor planning difficulties or hypersensitivities to environmental stim-
uli, then an occupational therapist should also be a part of the evalua-
tion team.
Because the majority of children and adolescents with DBD have lan-
guage/learning and ToM impairments, all students diagnosed with ODD
or CD should regularly receive a comprehensive language assessment.
Such an assessment should not be limited to evaluation of vocabulary
and syntactic skills but should also include evaluation of conversation
and narrative discourse skills and the ability to make inferences from
oral and written discourse. With awareness of the likelihood of ToM
deficits in children and adolescents with DBD, their cognitive and affec-
tive ToM skills should also be assessed. Cognitive and affective ToM
skills are also essential if social skills and cognitive behavior therapy are
to be effective (refer to Chapter 2 for dimensions or types of ToM). There
are no standardized tests that assess the range of development of ToM
skills, but there are a number of research articles that describe tasks for
evaluating first-order ToM (thinking about what someone is thinking or
feeling) and second-order ToM (thinking about what someone is think-
ing or feeling about someone else; e.g., Pons, Harris, de Rosnay, 2004;
Wellman & Liu, 2004) and higher order ToM, such as sarcasm, faux pas,
and figurative language, in which what is said is different than what is
meant (O’Hare, Bremmer, Happé,  & Pettigrew, 2009). Because of the
high incidence of affective empathy ToM deficits in students with DBD,
this area ideally should be assessed. Although some questionnaires and
assessments for measuring affective empathy are reported in the litera-
ture, they are generally not readily available (the Kids’ Empathic Devel-
opment Scale that assesses empathy of 7- to 10-year-olds in response
to scenarios; Reid, Davis, Horlin, Anderson, Baughman, & Campbell,
2013; the Interpersonal Reactivity Index, a self-reported question-
naire for persons 10 years and older that assesses cognitive and affec-
tive empathy; Davis, 1980; and the Kiddie Mach; Christie & Geis, 1970,
another self-reported questionnaire assesses Machiavellian traits in chil-
dren 11 years and older). These questionnaires require reasonably good
 Children With Disruptive Behavior • 331

language skills and some degree of intrapersonal ToM (ability to reflect

on one’s thoughts and emotions), both of which are likely to be prob-
lematic in students with DBD.
Because Alec was not making progress in reading at the end of second
grade, he was referred for an academic assessment. Testing indicated that
Alec had superior visual perceptual skills, average language skills, and low
average working memory and processing speed skills. He met criteria for
dyslexia. In third grade, he received resource room support for reading and
written language. In fourth grade, Alec was placed in a twice-exceptional
program for gifted students with learning disabilities. In fifth grade, he
was suspended, then transferred to another school with a program for
students with EBD, suspended from that program, and then placed in a
homebound educational program. Testing at the end of that year revealed
markedly lower scores than earlier testing. His overall performance on
intellectual testing was in the borderline range. Perceptual skills and com-
prehension scores were in the borderline range and processing scores
were in the extremely low range. Although reading, writing, and math
scores indicated significant impairment, his score on the Peabody Picture
Vocabulary Test (Dunn & Dunn, 2007) was in the low average range, so
Alec was not referred for a language evaluation. In the summer follow-
ing sixth grade, he attended a language/literacy camp where the Clinical
Evaluation of Language Fundamentals, fourth edition (CELF-4; Semel,
Wiig, & Secord, 2003) was administered. Alex obtained a score of 68. His
narratives were disorganized action or reactive sequences rather than sto-
ries with problems and solutions. He made little use of dependent clauses
to signal temporal and causal relationships between events.

INTERVENTION FOR CHILDREN AND

ADOLESCENTS WITH DBD
DBD are difficult to treat, especially if longstanding and accompa-
nied by CU traits. Many of the interventions that have been used with
children and adolescents with DBD have been generic—providing all
referred persons with the same curriculum. To be effective, any inter-
vention needs to address the full range of the child’s difficulties, at home,
school, and the wider community, in a developmentally appropriate
way. All the strategies described in this chapter require a certain level of
language and ToM skills to participate effectively. Therefore, the most
basic treatment for children and adolescents with DBD must recognize
and treat language/learning impairments and ToM.
332 • Westby

Interventions need to match students’ specific strengths and needs.

Not attending to these variations can result in interventions that are
counterproductive. Persons with CD and combined language or learning
impairments are likely to exhibit deficits in social cognitive knowledge,
pragmatic skills, and ToM. Students with this pattern of DBD might benefit
from interventions that explicitly teach social skills and ToM (Adams et al.,
2012). In contrast, some students with CD and Machiavellian or CU traits
have good knowledge of expected social conventions and good cognitive
ToM skills. Interventions that address these skills for students with Machi-
avellian traits are at best a waste of time and at worst can provide them with
skills that enable them to be more manipulative. With the inclusion of the
CU traits to the CD description, there is increased interest in and aware-
ness of the need to address empathy, both cognitive affective ToM, that is,
awareness and interpretation of the emotions of others and the ability to
regulate one’s emotions, and affective empathy, which is the ability to feel
and respond to the emotions of others. Some programs or curricula for
students with DBD teach aspects of emotional awareness in self and others
(Southam-Gerow, 2013), but there has not been any systematic investigation
of the effectives of focusing on developing affective ToM in these students.
Designing interventions for children and adolescents with DBD needs
to employ a dynamic systems approach, which acknowledges that there
are many intrinsic (internal neurologically based) and external (envi-
ronmental) factors that influence all aspects of development. These fac-
tors interact in different ways within each individual. Nelson, Craven,
Xuan, and Arkenberg (2004) have used the term “dynamic tricky mix” to
refer to this variable mix of environmental and intrinsic factors with dif-
ferent children. Because the individual and environmental factors differ
for each child and interact in different ways, no one invention is likely to
be equally effective for everyone. Interventions should be informed by
increasing the understanding of the psychopathology underlying con-
duct problems. Therefore, for early-onset ODD or CD, interventions
should focus on psycho-education and support for parents and school,
to avoid reinforcing undesirable behaviors. Problems with language, lit-
eracy and the ability to cope with peers, and the various types of ToM
should also be identified and addressed. Treating co-morbid psychiat-
ric conditions such as ADHD or depression is crucial. Interventions for
DBD need to address both environmental and individual characteristics
that contribute to the DBD (see Figure  11.1). A  variety of approaches
have been used to treat students with DBD including schoolwide inter-
ventions, parent training in behavior management, child-directed inter-
ventions focused on social skills or cognitive behavior management, or
multisystemic systems that integrate components from all the approaches.
Despite the fact that the majority of students with DBD have language
 Children With Disruptive Behavior • 333

Contextual
Individual ODD/CD Environmental
Family
Characteristics Criteria Met Characteristics
Factors

Possible
Parenting
Genetic
Practices
Bases

CU
Machiavellian Peer
Narcissism Factors
Traits

Community
ToM Skills & School
Factors

FIGURE 11.1 Dynamic Tricky Mix of Individual and Environmental Treatment Factors

impairments and deficits in ToM, there is not a body of literature on the

effects of simultaneously addressing the language and ToM impairments.

Schoolwide Interventions
With increasing awareness of instances of bullying, schools are imple-
menting school or district-wide programs to prevent and reduce vio-
lence. Positive behavioral supports (PBS) is among the most well-known
of these programs. PBS employs principles of applied behavior analysis
and nonpunitive, proactive, systematic techniques. The theory behind
PBS is that problem behavior continues to occur because it is con-
sistently followed by the child to get something positive or to escape
something negative. PBS strategies fit the needs of children with DBD,
particularly those with CU traits, who are known to be unresponsive to
interventions that take away privileges for misbehavior. PBS focuses on
the contexts and outcomes of the behavior to determine the functions of
the behavior, and in so doing, the goal is to make the problem behavior
334 • Westby

less effective for the child and make desired behaviors more functional.
All school staff are trained in PBS so there is consistency in expectations
and strategies for managing behavior in all school contexts. Schoolwide
PBS programs have three tiers (Tobin & Sugai, 2005). The primary level
is intended to be a schoolwide prevention program that involves using
effective teaching practices, explicitly teaching behavior that is expected
and acceptable in the school environment, using consistent correction
practices, and creating reinforcement systems that are used schoolwide
(Nelson, Martella, & Marchand-Martella, 2002).
Children and adolescents with DBD require more than tier one
interventions. The second intervention tier is for students who do not
respond to the primary prevention strategies. Secondary interventions
usually include social skills training and academic support typically
delivered in small groups. Children with DBD, who exhibit persistent
disciplinary problems, will require the third intervention tier. At this
level, school staff conduct a functional behavioral assessment of the
student, determining antecedent events that precede the inappropriate
behavior, describing the behavior, and identifying the consequences of
the behavior that might explain what is reinforcing it. This information is
then used to design intervention programs to increase prosocial behav-
iors by giving clearer instructions and positive reinforcement. Antiso-
cial behavior is decreased by a range of behavioral techniques such as
extinction, overcorrection, time-out from positive reinforcement, and
teaching and reinforcing prosocial behavior that is incompatible with
the antisocial behavior. At Tiers 2 and 3, PBS plans are individualized
and include procedures for monitoring, evaluating, and reassessing the
process.
Meta-analysis of schoolwide and individual PBS programs have
demonstrated effectiveness. Schoolwide programs have resulted in sig-
nificant reductions in student suspensions and disciplinary referrals
(Bradshaw, Mitchell, & Leaf, 2010). Meta-analysis of studies of individ-
ual students with a variety of different disabilities participating in PBS
programs indicated moderate effects in increasing appropriate skills and
decreasing problem behavior (Goh  & Bambara, 2012). Unfortunately,
studies have seldom investigated generalization or long-term effects of
individualized PBS.
Parent Management Training
Because conduct problems often arise in disadvantaged families,
broader family problems may need to be targeted. This can be challeng-
ing because family members may not recognize their role in the child’s
problems or may not have the motivation to be involved in interventions.
 Children With Disruptive Behavior • 335

Because some of the behaviors associated with DBD are highly inher-
itable, particularly CU traits, a number of parents of children with
DBD are likely to exhibit behavioral problems themselves, which may
compromise their response to training. Children with DBD put stress
on their families, even healthy families with involved, caring parents.
Hence, parents of any child with significant behavioral problems can
potentially benefit from parent management training.
The rationale for parent management training is based on the view
that conduct disorders are inadvertently developed and sustained in the
home by maladaptive parent–child interactions (K. Baker, 2013). Parent
management training teaches parents to pay attention to and reinforce
desirable behaviors and to use strategies for dealing with unwanted
responses. The characteristics of the child and family affect the out-
comes of parent training programs. For example, boys, ages 4 to 9 with
and without CU traits, responded equally well to the part of an interven-
tion that focused on teaching parents methods of using positive rein-
forcement to encourage prosocial behavior, but only the group without
CU traits showed added improvement with the part of the interven-
tion that focused on teaching parents more effective discipline strategies
(Hawes  & Dadds, 2005). Comorbidity in the child, such as untreated
ADHD, language disorders, and learning difficulties, may also reduce
the efficacy of parent programs. Failure to benefit from parent training/
education programs is also associated with parental disadvantage, lack
of parental perception of a need for an intervention, and parental men-
tal health problems, especially alcohol and drug problems, personality
difficulties and depression (K. Baker, 2013).

Child- and Adolescent-Centered Interventions

Child- and adolescent-centered interventions have been of two types,
social skills training, and cognitive behavioral therapy (CBT), both of
which are typically done with small groups of students. In school set-
tings, these interventions are often conducted jointly by a counselor, a
social worker, or a school psychologist, along with a speech-language
pathologist. This collaboration is critical because students’ ability to
participate in these interventions is dependent upon adequate compre-
hension and use of the language of the curricula, and many students
with DBD have significant language impairments that could compro-
mise their ability to participate adequately.
Social skills and CBT interventions are typically conducted in groups.
There is evidence, however, that placing aggressive or antisocial chil-
dren and adolescents in group therapy may exacerbate the unwanted
behaviors (Lochman  & Pardini, 2008; Poulin, Dishion,  & Burraston,
336 • Westby

2001). When youngsters with conduct disorders are placed together, in

the absence of children with prosocial behavior, that is, without conduct
disorder, peer bonding to deviant group members may occur and rein-
force antisocial attitudes, values, and behaviors.

Social Skills Programs

Observation of the behaviors of children and adolescents with ODD
and CD might suggest that they have social skills deficits and that teach-
ing social skills would result in improved behavior. Although it is likely
that some children and adolescents with DBD do lack knowledge of
social skills, this is far from true for all of them. Sanger, Coufal, Schef-
fler, and Searcy (2003) found no difference between incarcerated and
non-incarcerated adolescent girls in their pragmatic knowledge of the
rules governing conversational practices according to societal dictates.
Being able to state the rules for polite conversations, however, did not
ensure that they used their knowledge in interactions.
Social skills training and programs to improve problem-solving skills
seem to have high face validity, but they have not been demonstrated to
be effective in any age group as a stand-alone intervention for children
and adults with DBD. Trials of social skills training in adolescents with
antisocial behavior reveal no evidence that the skills are generalized
beyond the treatment setting, and therefore, these have limited impact
on the delinquent behavior (K. Baker, 2013). Social skills training can
have a role in the treatment of students with DBD who do lack knowl-
edge of the rules of social interaction, but it is not an effective use of
time and resources for students who have the pragmatic knowledge but
do not use it. Those students require a careful assessment to determine
what contributes to their lack of use of social cognitive knowledge.
Although some children and adolescents with DBD do have knowl-
edge of social rules, many with DBD have distorted perceptions of social
events and the intents of others and they use these distorted percep-
tions to justify their inappropriate behaviors. They tend to see hostile
intents in many interactions and they fail to consider multiple cues when
interpreting the meaning of others’ behavior. Improving ToM skills in
these individuals could result in more appropriate behaviors. Programs
that incorporate role-play and creative dramatics may have the potential
to improve students’ cognitive and affective ToM skills if attention is given
to identifying body and facial cues of emotions, noting and discussing
factors in the situations that trigger emotions, and discussing how charac-
teristics of persons affect their thoughts, beliefs, and emotions. Children
are taught to identify and label different emotions and the situations in
which they occur. The therapist may model expression of feelings and
 Children With Disruptive Behavior • 337

empathizing with others in addition to using pictures and games to increase

emotional understanding. Such interventions have had some success in
improving cognitive ToM and cognitive affective ToM in persons with
language impairments or autism spectrum disorders (Charlop-Christy &
Daneshvar, 2003; Feng, Lo, Tsai,  & Cartledge, 2008; Wolf et  al., 2008).
Developing cognitive and cognitive affective ToM has proved easier than
cognitive empathy has. But a study that provided either supplemental
creative dramatics or art/music to neurotypical elementary and high
school students did find that participation in creative dramatics over an
academic year resulted in significantly improved scores on measures of
affective empathy (Goldstein & Winner, 2012). Educators and clinicians
need to be careful in teaching ToM skills, however. Improving ToM skills
in students with Machiavellian traits or bullying tendencies may increase
their abilities to manipulate and use others for their own ends.

Cognitive-Behavioral Interventions
Social skills programs may be integrated with CBT, which is designed to
improve the child’s understanding not only of interpersonal situations
but also of their own thoughts and emotions as a means to improving
their problem-solving abilities. The underlying concept behind CBT is
that our thoughts and feelings play a fundamental role in our behavior.
CBT focuses on examining the relationships among thoughts, feelings,
and behaviors; hence it is a method for developing intrapersonal cogni-
tive and affective ToM. Intrapersonal ToM involves reflecting on one’s
own thoughts and emotions and using this knowledge to regulate, plan,
and monitor one’s behavior.
Many of the behaviors exhibited by children and adolescents with
DBD indicate their need for improved intrapersonal ToM. They tend to
underestimate their own level of aggression and responsibility in argu-
ments. They have a positive view of aggression, believing it is a nec-
essary, if not an appropriate, approach to social problem solving and
reduction of negative consequences. Their use of aggressive behavior
enhances their self-esteem, and they value social goals of dominance
and revenge more than affiliation (Bailey, 1996). When highly aroused,
upset, or in situations that might cause upset feelings, they have fewer
feelings of fear or sadness and respond aggressively. When problem
solving, children with CD generate fewer verbal assertive solutions and
many more action-oriented and aggressive solutions to interpersonal
problems (Dodge & Newman, 1981).
CBT requires verbal ability and some degree of insight or ToM. Given
that many children and adolescents with ODD and CD have language
impairments and ToM deficits, speech-language pathologists will likely
338 • Westby

need to modify CBT programs to include development of the language

and ToM skills essential for participating. Although CBT programs
often acknowledge a role for emotions in behavior, they have typically
focused on employing cognitive factors (cognitive ToM—dealing with
thoughts and beliefs) to problem solve. CBT components generally
include the following (L. L. Baker & Scarth, 2002):
• Defining the problem
• Generating solutions to the problem
• Evaluating possible solutions and selecting one
• Implementing the solution
• Evaluating the outcome.
A combination of modeling and self-instructional language training are
used to teach children to control their impulsive behaviors, problem
solve, and deal with frustration and failure in goal-directed activities
(Kendall  & Braswell, 1993; Meichenbaum, 1977). Older students also
are engaged in cognitive restructuring—rethinking their behavior, rec-
ognizing their thoughts that led to antisocial actions, and examining
and changing those thoughts to minimize chances of future misconduct.
There has been an increasing recognition of the need to address emo-
tional factors in treatment and include activities to promote recognition,
understanding, and regulation of emotions (Committee for Children,
2011; Conduct Problems Prevention Research Group, 2010; Greenberg &
Kusche, 2006; Southam-Gerow, 2013; Webster-Stratton, Reid, & Stoolm-
iller, 2008). Compared to children in control groups, children participating
in these programs had improvements in social problem solving, emotional
understanding and self-control and lower rates of conduct problems.
Vaske, Galyean, and Cullen (2011) suggest that CBT programs incorpo-
rating affective components are more likely than other interventions to
result in behavioral changes because tasks involving perspective taking,
emotional understanding, and emotionally regulate activate areas of the
brain shown to be dysfunctional in persons with antisocial behaviors.

A Language Intervention Approach to DBD

We tell ourselves stories, and we live by the stories we tell ourselves.
Children and adolescents with DBD are not good at telling themselves
stories. Noel (2011), a speech-language pathologist with extensive expe-
rience with children and adolescents with DBD and the intervention
programs described in this chapter, has employed a narrative-based
intervention to address the language and problem-solving needs of
youth offenders. Narrative discourse is dependent on ToM skills. When
relating personal narratives, one needs to be able to reflect on and
evaluate past experiences, not just list the event or experience.
 Children With Disruptive Behavior • 339

Reflection and evaluation require intrapersonal ToM when thinking

about one’s own intents and emotions and interpersonal ToM when
thinking about the reasons for the behaviors of others. Noel explicitly
has taught incarcerated adolescents the components of stories, using
what she calls the SPACE storytelling strategy, and then has had them use
these skills. When retelling stories they had read, listened to, or viewed,
adolescents were taught to organize their stories with these components:
• Setting (S): Who is involved? When does it happen? What’s go-
ing on?
• Problem (P): What is the problem? How do the characters feel?
What do the characters need or want?
• Action (A): What did the characters do?
• Consequence (C): What was the result of the character’s action
• End/evaluation (E): How did the story end? What was the les-
son learned? How do you feel in response to the story?
Once students were able to retell stories using the SPACE storytelling
strategy, they were instructed in the BEST PLANS social problem-solving
strategy. Students were taught the components and process using the
mnemonic BEST PLANS. This strategy has nine steps: (1) Be aware of
the setting. (2) Examine the problem. (3) Set an end goal. (4) Think about
what you could do. (5) Predict the possible consequences. (6) Label
your decision. (7) Arrange a plan and take action. (8) Notice the conse-
quences. (9) Study the end; did the plan work? These steps were taught
embedded in a modified SPACE framework. The adolescents used the
BEST PLANS framework to produce narratives of their own experi-
ences. Compared to their preintervention language and problem-solving
samples, the youth offenders who participated in this narrative language
intervention produced structurally more complex narratives, greater
inclusion of social problem-solving, and greater use of landscape of
consciousness in their postintervention personal narratives; that is, they
made more reference to the mental states and emotions of themselves.

MULTISYSTEMIC THERAPY
Multisystemic therapy (MST) is a multicomponent program for ado-
lescents with serious conduct disorders that combines all the inter-
vention elements already discussed. This approach recognizes the
multidimensional nature of serious antisocial behavior, so it draws on
a broad spectrum of techniques to address individual, parental, fam-
ily, and peer relationship problems. The main treatment interventions
include family therapy, parent training, marital therapy, and supportive
340 • Westby

psychotherapy related to interpersonal problems, social skills compo-

nents, and cognitive behavioral therapy, as well as case management
in which the therapist acts as an advocate to outside agencies for the
young person and family. The main goal of MST is to give parents
the skills and resources needed independently to address the difficulty
of raising adolescents while also empowering the young person to
cope with family, peer, and school problems. MST was more effective
in reducing externalizing behavior in adolescents with lower CU or
lower narcissism traits than in those with high CU or high narcissism
(Henggeler, 2011; Manders, Dekovic, Asscher, van der Laan, & Prins,
2013). It was more effective than other methods in decreasing exter-
nalizing behaviors (including fewer arrests, less serious offenses, fewer
weeks of incarceration) in adolescents, but not in reducing psycho-
pathic traits per se.
The summer following sixth grade, Alec was enrolled in a 9-week
summer language/literacy camp. Each daily session was divided into
three components: decoding/orthographic skills, narrative comprehen-
sion/production, and science activities to build expository language
skills and social skills through collaborative problem solving. Sentence
frames were used to develop Alec’s syntactic skills to express emotional
relationships in narratives (When _____ [what happened] the character
felt ____ [emotion], because _____ [reason for emotion]) or ration-
ales for characters’ intentional behaviors (The character wanted _____
[intent, goal, objective] because _____ [reason for goal] but _____
[obstacle to achieving goal], so _____ [what character did to overcome
obstacle and achieve goal]). He watched videos of interactions, noting
expressions and tone of voice of the characters to interpret characters’
thoughts and feelings and to predict what characters would do. The clini-
cian taught strategies for decision making and problem solving by using
a framework proposed by Elias (2004) for students with social-emotional
difficulties. Alec was asked to identify problems faced by characters in
narratives, identify and evaluate their solutions to the problems, then
apply the problem-solving strategies to his own experiences.

IMPLICATIONS
Children with DBD present with complex individual and environmen-
tal factors that affect their behavior and social interactions. Results of
studies evaluating interventions suggest that attention to these multi-
ple factors and the subtypes of aggressive children likely will enhance
the effectiveness of interventions (Caldwell, Skeem, Salekin,  & Van
 Children With Disruptive Behavior • 341

Rybroek, 2006). CU traits are associated with poorer treatment out-

comes in samples of antisocial youths (Frick & Dickens, 2006). Multi-
component programs that integrate or fuse programs into one coherent
intervention have been shown to be the most effective for children and
adolescents with DBD. Effects of most single intervention programs are
modest. This may be due to equifinality; that is, different risk factors
lead to the same behavioral problems. Consequently, treating only the
observed behavior does not necessarily address the factors contributing
to behavioral problems in a specific child.
Children with differing environmental influences, comorbid con-
ditions, patterns of behavior, and psychopathic traits require differing
approaches to interventions. School discipline for students with DBD typ-
ically employs punishments, for example, time-outs, denial of privileges,
or suspensions. Children with CU traits, however, are not intrinsically
motivated to “do the right thing” and tend to be reward oriented; punish-
ments have little effect on changing their behaviors. These children tend
to respond better to programs that provide clear, tangible external rein-
forcements for appropriate social behavior and teach empathy (Caldwell
et al., 2006; Wong & Hare, 2005). Interventions for children with DBD and
narcissistic traits might need to replace unconditional and excessive praise
with tangible rewards and assistance in learning to cope with receiving
negative feedback (Barry, Frick,  & Killian, 2003). Interventions for stu-
dents with DBD and Machiavellian traits might need to modify the larger
social climate in which such behavior takes place. Students with Machi-
avellian traits obtain rewards through manipulating others, often in subtle
ways that go unnoticed. Teachers and staff must be alert to manipulative
behaviors if they are to reduce the social rewards students are achieving
(Olweus, Limber, & Mihalic, 1999). Sutton and Keogh (2000) further sug-
gest engaging the students in discussions about interpersonal trust and
the values of cooperation, but caution that children with Machiavellian
traits are less inclined to keep their side of behavioral contracts. If students
with DBD are to be able to respond to the interventions described in this
chapter, they must have adequate language and ToM skills. Because the
majority of children and adolescents with DBD are at risk for impairments
in these areas, speech-language pathologists need to be part of the teams
that serve them.

DISCUSSION QUESTIONS
1. Discuss the ways that environmental conditions and individual
(and genetic) characteristics interact in DBD.
342 • Westby

2. Describe the patterns of behaviors you might see in children

and adolescents with DBD. Why is it important to recognize the
specific behavioral patterns exhibited by students with DBD?
3. How would you approach assessment of a student with DBD?
4. Many efficacy studies of interventions for DBD have shown
only modest effects. Why might this be the case?
5. Develop a language-based intervention plan for a student with
DBD with CU traits. Consider the vocabulary, syntactic pat-
terns, discourse structures, and ToM concepts that would be
addressed.

INSTRUCTIONAL RESOURCES
Baron Cohen, S. Zero Degrees of Empathy. Retrieved from www.youtube.com/
watch?v=Aq_nCTGSfWE
Cognitive Behavioural Approaches to Treating Children  & Adolescents with
Conduct Disorder. Retrieved from www.kidsmentalhealth.ca/docu-
ments/Cognitive_Behavioural_Conduct_Disorder.pdf
Dennis Embry, How Are the Children?: www.youtube.com/watch?v=h7
olxaYofdk
Emotion in Education: An Interview with Maurice Elias. Retrieved from www.
edutopia.org/maurice-elias-sel-videoKids at Hope website. www.kid
sathope.org/
Nelson Muntz—A Simpson’s Case Study in Conduct Disorder. Retrieved from
www.youtube.com/watch?v=lLU3agENOFc
Oppositional Defiance—Easy Strategies for Dealing with ODD Disorder:
Smart Discipline: www.youtube.com/watch?v=EkJtcO8t_3E
Oppositional Defiant Disorder: www.youtube.com/watch?v=uoXBFOZml80
Positive Behavior Supports website: www.resa.net/curriculum/positivebehavior/
Second Step Program website: www.cfchildren.org/second-step.aspx
Stewie Griffin—A Case Study in Oppositional Defiant Disorder (more conduct
disorders): www.youtube.com/watch?v=rdG_1_Pic8Y
TED Talks: The Challenge of Early Conduct Disorder, Derek Patton. The Vir-
tues Project. Retrieved from www.youtube.com/watch?v=uptMwDiJn-
I&list=PL2CBRa7760FwnN6kNh89e4rGhM8W6BcqL&index=8 Or
www.virtuesproject.com/rfacilitators.html

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 INDEX

Note: Page numbers followed by f indicate a figure on the corresponding page. Page
numbers followed by t indicate a table on the corresponding page.

abnormalities of intonation 147 Applied Behavioral Analysis (ABA) 185,

Aboriginal children 96 186 – 7
Adams, Catherine 15, 223 Asian cultures 67, 71, 127
adjustment disorder 290, 291 Asperger’s Disorder: cognitive ToM with
Adult Attachment Interview 68 29; evidence-based treatment for 187;
affective cognitive ToM 28 – 30, 325 – 6 multiple names for 173; overview 177;
affective empathy ToM 28 – 30 speech-generating devices 196 – 7,
affective ToM 23, 24, 30, 61 198 – 9; story-based intervention
Agency for Healthcare Research package 200 – 1; video modeling
Quality 174 interventions 199 – 200
Alcoholics Anonymous (AA) 51 Assessment of Comprehension and
Alcohol-Related Birth Defects Expression (ACE) 151
(ARBD) 261 associated developmental difficulties 149
Alcohol-Related Neurodevelopmental attachment: attunement 52 – 6, 67;
Disorder (ARND) 261 avoidant insecure attachment 54;
American Academy of Neurology 178 classifications 68 – 9; disorganized
American Academy of Pediatrics (AAP) insecure attachment 55; insecure
178 attachment relationship 54, 62;
American Psychiatric Association (APA) Reactive Attachment engagement
6, 176, 290 disorder 290; resistant insecure
American Speech-Language-Hearing attachment 54 – 5
Association (ASHA) 13, 178 attention: cultural differences 95;
amygdala 27 – 8, 89 development of 82 – 4; executive
Anglo-American preschoolers 97 functioning and 35; factors affecting
anterior cingulate cortex (ACC) 34 93 – 4; focused attention 66, 84, 93,
anxiety disorders 321, 323 109 – 10; selective attention 94
352 • Index

Attention Deficit Disorder with or Behavior Rating Inventory of Executive

without the Hyperactivity (ADD/ Function (BRIEF) 268, 276
ADHD): defined 254 – 6; disruptive BEST PLANS social problem-solving
behavior problems 321; evidence- strategy 339
based intervention 268 – 77, bidirectional processing of stimuli 10
271t – 273t; incidence and prevalence bilingual children 99
256 – 7; introduction 6; language and Bilingual Multicultural Services 15
social communication development bottom-up processing of stimuli 10
257 – 60; learning objectives 252 – 3; Brinton, Bonnie 16
oppositional defiant disorder and bullying behaviors 324
323; overview 253 – 4; reputational
bias 274; treatment as co-morbid callous and unemotional (CU) traits
condition 332 323 – 6, 332, 340 – 1
attunement and attachment 52 – 6, 67 caregivers: child relationship and 52 – 6,
Augmentative and Alternative 65, 110; communication by 112 – 13;
Communication (AAC) 173, 196 – 7, maltreatment exposure treatment
233 305 – 8; maternal maltreatment 292 – 3;
Autism Diagnostic Interview – Revised mind-sets 66 – 8
(ADI-R) 182 case/single-subject design study 14, 241
Autism Diagnostic Observation Schedule Centers for Disease Control and
(ADOS) 182 Prevention (CDC) 256, 260, 262
Autism Spectrum Disorder (ASD): central nervous system (CNS)
assessment/evaluation for 150; development 261
behavioral packages 186 – 9; Child Behavior Checklist (CBCL) 265
characteristics of 175 – 7; Child Find screening 3
comprehensive treatment Childhelp National Child Abuse Hotline
programs 186; deficits in ToM 299
abilities 37; diagnostic criteria for Childhood Disintegrative Disorder 176
222; dopaminergic-serotonergic Child Mental Health Foundation and
(DS) system 38; evidence-based Agencies Network Project 126
intervention 182 – 202, 183t – 184t; Child Neurology Society 178
eye-tracking measures 31 – 2; focused Child Protective Services 299
intervention strategies 196 – 202; Children’s Communication Checklist
high-functioning 144, 145, 147, 154 – 5, 235, 266, 304
149; interventions with 157, 306; Child Trauma Assessment Center 300 – 1
introduction 6, 16; learning disorders Child Welfare Information Gateway 299
171; overview 171 – 4; practices 181 – 2; classroom-based interventions 160,
referral guidelines 178 – 9; repetitive 274 – 5
behaviors 12; restricted interests Clinical Evaluation of Language
dimension of 155; screening 179, 180t; Fundamentals (CELF) 151, 152, 162,
single-subject research 240; social 221, 239, 331
communication problems 22, 225; see cluster reduction 116
also Asperger’s Disorder Cochrane systematic review 156 – 7
autobiographical memory 36 – 7, 90 cognitive behavioral therapy (CBT)
Autonomic Nervous System 335 – 6, 337 – 8
(ANS) 57, 62 cognitive constructivist theories 7 – 8
avoidant insecure attachment 54 cognitive flexibility 34
 Index • 353

cognitive processes: attention developmental – social model of

development 82 – 4; executive function intervention 157
93 – 4; learning objectives 79 – 81; Developmental Therapist (DT) 181
memory development 88 – 91; mental Diagnostic and Statistical Manual of
representations of 91 – 3; social Mental Disorders (DSM) 6, 15, 143,
understanding 84 – 8, 85t; typical 175 – 7, 254 – 5
development 81 – 94, 85t differential-sensitivity hypothesis 38
cognitive ToM 23, 25, 27 Discrete Trial Training (DTT) 188 – 9
Collaborative for Academics, Social, and Disinhibited Social engagement disorder
Emotional Learning (CASEL) 238 290
collectivism 42, 69, 96, 99 disorganized insecure attachment 55
Communication and Symbolic Behavior disruptive behavioral disorder (DBD):
Scales-Developmental Profile assessment of 328 – 31; cognitive
(CSBS-DP) 152, 304 behavioral therapy 335 – 6, 337 – 8;
Comprehensive Assessment of diagnostic criteria for 321 – 4;
Neuropsychological Development in implications 340 – 1; interventions
Children – 2nd Edition (NESPY-2) 267 for 331 – 9, 333f; introduction 6,
comprehensive treatment model (CTM) 16; language disorders with 326 – 8;
186, 195 language intervention approach to
conduct disorders (CDs): cognitive 338 – 9; learning objectives 320 – 1;
behavioral therapy 335 – 6, 337 – 8; multisystemic therapy 339 – 40;
comprehensive language assessment parent management training 334 – 5;
needs 330; diagnostic criteria schoolwide interventions 333 – 4;
321 – 4; executive functions and 328; social-emotional competence and
interventions for 331 – 2; social- 325 – 6; social skills program 336 – 7
emotional competence and 325 – 6; dopamine 38 – 9
social skills program 336 – 7 dopamine receptor DRD4 gene 39 – 40
connectionism theory 9 – 11 dopaminergic-serotonergic (DS) system 38
conversational exchanges 124 – 5 dorsal anterior cingulate cortex
cool EF processes 35 – 6, 36t (dACC) 27
cooperative learning tasks 227 – 9 dorsal lateral prefrontal (dLPFC)
cortical midline structures (CMS) 33 cortex 27
cultural habits in child rearing dorsal medial prefrontal (dMPFC)
69 – 72, 71f cortex 27
culturally and linguistically diverse dorsolateral prefrontal cortex (dlPFC) 34
(CLD) backgrounds 173, 175 dorsomedial thalamus 27
cultural neuroscience 41 – 2 dynamic systems theory (DST) 10 – 13,
Culture and Neuroscience (journal) 41 110, 289, 301, 332
dynamic tricky mix 332, 333f
Daily Behavior Report Card (DBRC) dyslexia risk 253
intervention 270
Dark Triad 324 early childhood special educator
decontextualization development 91 – 3 (ECSE) 51
deictic gestures 115 Early Intensive Behavioral Intervention
Developmental, Relationship-Based (EIBI) 188 – 9
Intervention (DIR) 194 – 5 Early Social Interaction Project (ESI)
Developmental Quotient 193 192 – 4, 306
354 • Index

Early Start Denver Model (ESDM) 192 Expressive Receptive Recall of Narrative
electrocardiograms 22 Instrument (ERRNI) 151, 162
electroencephalography (EEG) 22 eye-tracking measures 31 – 2
electromyograms 22
emerging interventions for autism 186 face-to-face interactions 58, 110, 113,
emotional and behavioral disorder (EBD) 306 – 7
321, 327; see also disruptive behavioral facial electromyography (EMG) 22
disorder facial expressions 5, 24, 30, 54, 58 – 59, 65,
emotional mimicry 25 82 – 84, 89, 95, 111 – 16, 237
English as a Second Language (ESL) 80 – 1 facial processing 30 – 2
Enhanced Milieu Teaching (EMT) 192 failure to thrive 109 – 10, 129, 294
environmental risk factors: antisocial false beliefs 86 – 8, 298
youth and 324; autism and 176; false belief tasks 26 – 7, 96, 293 – 4
disruptive behavioral disorder 328, Family Check-Up (FCU) intervention
340; Dynamic Systems Theory and 275 – 6
289, 332; gene expression impact Fannin, Danai Kasambira 16
21; maltreatment exposure 299; Fetal Alcohol Spectrum Disorder
neuroanatomical development 23, (FASD): defined 260 – 1; evidence-
40 – 1; social emotional development based intervention 269; incidence and
51, 112; susceptibility to 38; prevalence 261 – 3; language and social
toxins 69 communication development 263 – 4;
epenthesis 116 medical and psychological referrals
epigenetics 21 – 3, 41 264 – 5; overview 51, 254; referral
Epigenetics and Chromatin (journal) 21 guidelines and assessment
episodic memory 37, 89 – 90 practices 264 – 8
established interventions for autism 186 fight-or-flight reflex 55 – 6
ethnographic interview 301 Floortime treatment 194 – 5
European parents 70 – 1 focal brain lesions 22
event-related potentials (ERPs) 22 focused attention 66, 84, 93, 109 – 10
evidence-based intervention practices Friendship theory 8
(EBP): Asperger’s Disorder 187; frontal lobes and executive functioning 34
attention problems 268 – 77, Fujiki, Martin 16
271t – 273t; autism 182 – 202, Functional Communication Training
183t – 184t; classroom-based (FCT) 187 – 8
interventions 274 – 5; defined 13 – 15; functional emotional developmental
individual/small group interventions levels (FEDLs) 306
269 – 74, 271t – 273t; overview 268 – 9; functional magnetic resonance imaging
parent training 275 – 6 (fMRI) 22, 31, 42
executive functions (EFs): assessment fusiform face area (FFA) 30 – 1
of 267 – 8; cultural differences in future thinking 36 – 7
development 98 – 100; defined 255 – 6;
development 93 – 4; disruptive galvanic skin response (GSR) 22
behavioral disorder and 328; factors General Communication Composite 154
affecting 93 – 4; in ToM 33 – 7, 36t, general systems theory 12
98 – 9 genetic factors: cognitive processes 81;
explicit memory 88 – 9, 91 epigenetics 21 – 3, 41; neurochemistry
expressive language skills 4, 91 37 – 40, 39f
 Index • 355

gesture comprehension 115 interpersonal functions 120

goal setting and executive functioning 35 Interpersonal Reactivity Index 29, 40
Good Behavior Game 276 interpersonal regulation vs. intrapersonal
Greenspan, Alan 20 regulation 57 – 62, 59t
group designs 241 – 2 interpersonal relationships 109, 127,
group interventions 160, 240, 269 128 – 9, 190
interpersonal ToM 23, 30, 32 – 3, 32t
hierarchy of dependence 126 – 8 intersubjectivity and nonverbal
high-functioning autism (HFA) 144, 145, communication 112 – 16
147, 149 inter-ToM 85 – 6
hippocampus, development 90 intrapersonal ToM 23, 32 – 3, 32t, 331
homonym misinterpretation 148 intra-ToM 84 – 6
hot EF processes 35 – 6, 36t
Hwa-Froelich, Deborah 15, 16 Joint attention (JA) skills 193 – 4, 195
joint engagement states 172 – 3
illocutionary stage, of intentionality
119 – 21 Kasari, Connie 16
immunology 22 Korean children 127 – 8
implicit memory 88 – 9, 91
impulse types in children 64 – 5 language assessment: attention problems
independence/interdependence values 127 266, 267; disruptive behavior 301, 304;
indirect request development 122 – 3 maltreatment exposure 301, 304; PLI
Individual Education Program (IEP) and 142, 150, 151 – 2, 155
182, 186 language development: ambiguous
Individual Family Service Plan (IFSP) 182 language development 123; expressive
individual interventions 269 – 74, language skills 4, 91; Fetal Alcohol
271t – 273t Spectrum Disorder 263 – 4; foster care
individualism 42, 69, 96, 99 and 293 – 5; international adoptions
Indonesian parenting 98 296 – 8; maltreatment exposure 291 – 8;
inferences development 123 nonverbal language development 111,
inferior lateral frontal cortex (ILFC) 27 115t; oral language competency 117;
information processing theory 9 – 11 receptive language skills 4; social-
inhibition skills 83 – 4, 94 emotional development 66; speech
inhibitory control 34 – 5, 66, 88 and 116 – 18, 118t
insecure attachment relationship 54, 62 language disorders: attention problems
insula cortex 27 253, 265; disruptive behavior 326 – 8,
intelligence quotient (IQ) 80, 189, 263 335; disruptive behavioral disorder
intentionality 112, 119 – 20, 123, 127 326 – 8; language impairment and
interaction issues in language impairment 222; PLI and 142 – 3, 145; social
225 – 6 communication disorder 6
interaction theory 8 language impairment (LI): with ADHD
intermediate condition 144 257 – 60; case study 221; case
internal speech development 60 study outcomes 242 – 3; emotional
International Adoption Clinic 15 intelligence in children with 230 – 1;
international adoptions 296 – 8 factors influencing social outcomes
International Classification of Diseases-10 229 – 31; interaction issues 225 – 6;
(ICD-10) 177 introduction 222 – 3; language
356 • Index

processing 233 – 4; learning objectives 88 – 9, 91; long-term memory 10, 88,

220; negotiating for resources 226; 91 – 2; semantic memory 36 – 7, 89 – 90;
pragmatics 234 – 6; resolving working memory 34, 94, 331
disputes 226 – 7; social cognition mental representations 26, 52 – 3, 63,
236 – 7; social communication 90 – 1
assessment 231 – 8; social mental time travel 36
communication intervention metacognition 33 – 7, 36t
238 – 42; social communication Mexican parenting 97
problems 223 – 5; social mirror neuron system (MNS) 29 – 30, 33
communication skills 225 – 9; monoamine oxidase A gene (MAOA)
see also Pragmatic Language 38 – 9
Impairment monoamine oxidases (MAOs) 38
language intervention approach to DBD morphemes in utterances (MLU) 118
338 – 9 motherese, use of by children 122 – 3
Language Use Inventory (LUI) 152 multisystemic therapy (MST) 339 – 40
lead exposure in children 294
learning disabilities (LD) 239 narcissism 324, 340, 341
Learning Experiences and Alternative narrative discourse difficulties 327
Program (LEAP) 190, 195 narrative disorganisation 148
lesions in brain 29, 31 National Autism Center (NAC) 174, 185,
limbic – hypothalamic – 186
pituitary – adrenocortical axis 55 National Center for Evidence-Based
long-term memory 10, 88, 91 – 2 Practice in Communication Disorders
(N-CEP) 182
Machiavellianism 324, 325, 332 National Institute for Clinical Excellence
magnetoencephalography (MEG) 22 (NICE) 179
mainstream environments 125 – 6 National Institute of Child Health and
Making Socially Accepting Inclusive Human Development Early Child
Classrooms (MOSAIC) 274 – 5 Care Research Network 113
maltreatment exposure: assessment National Professional Development
practice 300 – 5, 302t – 303t; case study Center’s (NPDC) 185
outcomes 309; incidence, prevalence, National Research Council (NRC) 186
definitions 289 – 91; language and National Society for the Prevention of
social communication with 291 – 8; Childhood Cruelty (NSPCC) 290
learning objectives 287; maternal National Standards Project (NAC) 198
maltreatment 292 – 3; medical and Naturalistic Teaching Strategies 189 – 91,
educational assessment guidelines 193
298 – 305, 300t, 302t – 303t; overview neurochemistry: genetic factors affecting
288 – 9; possible signs of 300t; school- 37 – 40, 39f; social neuroscience 21, 23;
based treatment programs 308; theory of mind and 37 – 41, 39f
treatment practices 305 – 8 neuroimaging studies 35 – 7
memory: autobiographical memory neurotransmitters 38, 41
36 – 7; cultural differences in Nijmegen Pragmatics Test 154
development 96 – 8; development non-literal language 148
88 – 91; episodic memory 37, 89 – 90; nonverbal behaviors 5, 111
explicit memory 88 – 9, 91; factors nonverbal communication 112 – 16
affecting 93 – 4; implicit memory non-verbal IQ cut-off 155
 Index • 357

nonverbal language development incidence/prevalence 144 – 6;

111, 115t evaluation and differential diagnosis
154 – 5; evidence-based intervention
occipital face area (OFA) 30 156 – 61, 159t; learning objectives
Occupational Therapist (OT) 181 141; nature of 146 – 9; pragmatic
olfactory system 27 deficits 146 – 7; referral practices and
operations of reference 117, 118, 118t assessment 149 – 55; social interaction
oppositional defiant disorder (ODD): deficits 146, 148 – 9; structural
cognitive behavioral therapy 335 – 6, language deficits 146, 147 – 8
337 – 8; comprehensive language Pragmatic Language Impairment:
assessment needs 330; diagnostic conversational exchanges 124 – 5;
criteria 321 – 4; executive functions executive functioning and 256;
and 328; social skills program 336 – 7 intentionality 119 – 20; introduction
oral language competency 117 4 – 6; labeling of 222; politeness
orbitofrontal cortex (OFC) 34 rules 123; research on 15 – 16; social
oxytocin receptor gene (OXTR) 40 communication development and
111, 115t, 119 – 25; speech acts 120 – 3,
paralinguistic behaviors 147 120t; see also language impairment
parent intervention programs 160 – 1 Pragmatic Protocol checklist 152 – 3, 266
parent training 275 – 6, 334 – 5 pre-intervention stage assessment 156t
Peanut Butter Protocol 152 Preschool Language Scale-4
peer interventions/interactions 153, 158, (PLS-4) 51
160, 196, 227 Pre-Symbolic Play behaviors 173
perlocutionary stage, of intentionality primary intersubjectivity 82
119 – 21 problematic social outcomes 228 – 9
Pervasive Developmental Disorders progress charts, for rewarding behavior
(PDD) 156, 176 – 7, 194 – 5 270, 274
phonemes production 116 psychological ownership 308
Physical Therapist (PT) 181 Puerto Rican parents 66
Piaget’s theory of cognitive
development 7 quasi-experimental design study 14
Picture Exchange Communication
System (PECS) 196 – 8 randomized controlled trials (RCTs)
Pivotal Response Treatment (PRT) 191 – 2 188 – 9, 192, 201
placebo trials 265 Rapid Eye Movement (REM) sleep 90
play development 92 – 3 Reactive Attachment engagement
politeness rules 119, 122 – 3, 127, 224, 234 disorder 290
population, interventions, comparisons, “Reading the Mind in the Eyes” test 40
and outcomes (PICO) 13 receptive language skills: attention
positive behavioral supports (PBS) 333 – 4 disorders 258 – 9; delays 150, 154,
positron emission tomography (PET) 22 178, 234; interventions for 188, 200;
post-traumatic stress disorder 294 processing of 237; scores 51
Pragmatic Language Impairment, Relationship Development Intervention
assessment/intervention: associated (RDI) 194
developmental difficulties in 149; reputational bias 274 – 5
case study 142 – 3, 155 – 6, 156t; resistant insecure attachment 54 – 5
characteristics of 143 – 4; current Rett’s Disorder 176
358 • Index

Romanian institutional care 295, 297 – 8 social communication development:

Roth, Philip 20 assessing components of 233;
assessment 231 – 8; communicative
Sally – Anne task 26 – 7 partners and contexts 232 – 3; factors
schizophrenia 23, 38 affecting 125 – 9; foster care and
school-based treatment programs 308 293 – 5; hierarchy of dependence
schoolwide interventions 333 – 4 126 – 8; international adoptions 296 – 8;
Scottish Intercollegiate Guidelines interpersonal relationships 128 – 9;
Network (SIGN) 182 intersubjectivity and nonverbal
secondary intersubjectivity 82 – 3 communication 112 – 16; language
selective attention: cognitive processes impairment 225 – 9; learning objectives
81, 84, 94, 99; executive function 108 – 11; Pragmatic Language
and 304 – 5; social communication Impairment 111, 115t, 119 – 25;
development 111; social socioeconomic status 125 – 6, 129;
neuroscience of 35 speech and language development
self-regulation: attention development 82, 116 – 18, 118t; stakeholders 213
83, 93 – 4; attention problems 255, 367; Social Communication Disorder (SCD)
autism and 187, 195, 201; inhibition 143, 144
and 63 – 6, 64t; language as means to Social Communication Intervention
7; politeness rules 123; prelinguistic Programme (SCIP) 157 – 60, 159t
behaviors of 120; social-emotional Social Communication Questionnaire 156
development 15, 52 social competence: with autism
semantic memory 36 – 7, 89 – 90 201; defined 110; emotional
semantic relations 117 – 18, 118t understanding 56; foundations
serotonin 38 for 15; intersubjectivity and 112;
shaken baby syndrome 294 introduction 1, 4 – 10, 13, 15; with
simplification processes 116 language impairment 230; social
simulation theory of ToM 30 communication development 126, 127
single-cell recording 22 social emotional development:
single-subject research 14, 240 – 1 attachment and attunement 52 – 6;
small group interventions 269 – 74, caregiver mind-sets 66 – 8; cultural
271t – 273t habits 69 – 72, 71f; empathy 63; factors
social cognition 5, 224 – 5, 236 – 7 affecting 66 – 72, 71t; interpersonal
Social Cognitive and Affective regulation vs. intrapersonal regulation
Neuroscience (journal) 21 57 – 62, 59t; learning objective 50 – 2;
social communication: defined 5 – 6; physical and social environments
elementary school-age intervention 68 – 9; self-regulation and inhibition
157 – 60, 159t; intervention 238 – 42; 63 – 6, 64t
intervention choices 156 – 61, 159t; social interaction deficits 146, 148 – 9
language impairment 223 – 5; Social Interaction Deviance Composite
learning objectives 3 – 4; (SIDC) 154
maltreatment exposure 291 – 8, Social Language Development Test 153
302t – 303t; preschool intervention social learning theories 7 – 8
157; theoretical foundations social network analysis 233
7 – 13 social neuroscience: defined 21 – 8,
Social Communication Coding 24f, 28f; history of 21 – 2; learning
System 154 objectives 20 – 1; methods 22
 Index • 359

Social Neuroscience (journal) 21 temporal lobe 27

Social Rehabilitative Services 299 temporal parietal junction
social skills programs 201 – 2, 336 – 7 (TPJ) 27
Social Skills Training (SST) 160 Test of Language Competence 151
social understanding 84 – 8, 85t, 95 – 6 Test of Narrative Language 267
socioeconomic status (SES): autism Test of Pragmatic Language – 2 153
disorder and 175; evidence-based Test of Word Finding 151
practice 13; international adoptions theory of mind (ToM): affective cognitive
297; maltreatment disorder 291 – 2, ToM 28 – 30, 325 – 6; assessment of
293 – 4; politeness rules 123; prenatal 22 – 8, 24f, 28f; brain areas involved
alcohol exposure 262; social with 27 – 8, 28f; cultural neuroscience
development and 68, 125 – 6 41 – 2; current conceptualizations 237;
SPACE storytelling strategy 339 delays in children 325; dimensions
Spanish – English bilinguals 99 of 24f; executive function 33 – 7, 36t,
specific language impairment (SLI) 144, 98 – 9; facial processing 30 – 2; Fetal
145, 147 – 9, 222 Alcohol Spectrum Disorder and 263;
speech acts 120 – 3, 120t interpersonal ToM 23, 30, 32 – 3,
speech development 116 – 18, 118t 32t; inter-ToM 85 – 6; intrapersonal
speech-generating devices (SGD) 196 – 7, ToM 23, 32 – 3, 32t, 331; intra-
198 – 9 ToM 84 – 6; metacognition 33 – 7,
speech-language pathologist (SLP): 36t; metacognition and executive
ADHD evaluation by 253, 265 – 6; functions 33 – 7, 36t; neurochemistry
cognitive processes and 99 – 100; 37 – 41, 39f; overview 20 – 1;
evidence-based intervention practices processing 28 – 33, 32t; social
269; with maltreatment exposure understanding with 111, 112;
cases 288, 304, 307; play sessions 172; stages of 85t; treatment
prenatal alcohol exposure and 261; for 331 – 2
referrals to 150; social communication Timler, Geralyn 16
development and 129; social- token systems, for rewarding behavior
emotional development 51, 71; 270, 274
stakeholders and 232 top-down processing of stimuli
stakeholders in social communication 10, 30, 34
development 231 – 33 Training and Education of Autistic
story-based intervention package and Related Communication
200 – 1 Handicapped Children
Stress-Related Disorders 291 (TEACCH) 190
Strong Narrative Assessment Procedure Transactional model 8
(SNAP) 151 transcranial magnetic stimulation
structural language deficits 146, 147 – 8 (TMS) 22
Substance Abuse and Mental Health Trauma-Related Disorders 291
Services Agency (SAMHSA) 261 turn-taking difficulties 146
superior temporal sulcus (STS) 31
U.S. Child Protective Services 289
tag questions 127 – 8 U.S. Department of Health and Human
Targeted Observation of Pragmatics in Services (DHHS) 56
Children’s Conversation (TOPICC) U.S. Department of Health and Human
155, 162 Services 294
360 • Index

Using the Appraisal for Guidelines in Watson, Linda 16

Research Evaluation II 182 well-designed nonexperimental
utterance complexity 117 correlational design
study 14
ventral anterior cingulate cortex (vACC) 27 Westby, Carol 15
ventral medial prefrontal cortex Western parents 67
(vMPFC) 27 wh-questions 4, 292
verbal cues/behaviors 24 White, Katherine E. 16
video modeling interventions working memory 34, 94, 331
199 – 200 World Health Organization
Vietnamese parents 67 (WHO) 177, 290