Introduction
The following exercise is a case study of a young Swedish girl (‘Lena’) who was studied by Sahlén and Nettelbladt (Reference Sahlén and Nettelbladt1993) between the ages of 5;6 and 8;0 years. Lena was diagnosed as having semantic-pragmatic disorder, a subgroup within the group of specific and severe developmental language disorders. Nowadays, this group of children is labelled as having pragmatic language impairment or social communication disorder, the latter a diagnostic term used in DSM-5 (American Psychiatric Association, 2013). The case study is presented in five sections: history, hearing and cognitive evaluation; language profile at 5;6 years; language profile at 6;6 years; language profile at 8;0 years; and focus on pragmatics.
History, hearing and cognitive evaluation
Lena attends a language preschool unit for children with severe and specific developmental language disorders in Lund, Sweden. Staff at the unit reported that Lena at times behaves oddly. During pregnancy, Lena's mother had several infections of the upper respiratory tract and urinary tract. Apart from these infections, gestation was otherwise normal. Lena achieved motor milestones normally. At 2 to 3 years of age, there was a suspicion of autism. However, Lena's behavioural problems were later interpreted to be related to her language disorder. Lena experienced recurrent episodes of otitis media with effusion. However, screening audiometry, pure-tone audiometry and brainstem response audiometry all produced normal results. Some of Lena's family members have communication problems. Her two brothers – one older and one younger – are both receiving language training because of severe developmental language disorders. Lena's mother has a hearing impairment of unknown aetiology and wears a hearing aid at work. At 5;10 years, Lena underwent a speech discrimination test. She scored 78 to 86% (a score of > 90% is normal). The Raven's Coloured Progressive Matrices (Raven, Reference Raven1962) and the Swedish version of the Wechsler Intelligence Scale for Children (WISC; Wechsler, Reference Wechsler1976) were used to test Lena at 7;6 and 8;0 years, respectively. On the WISC, there was a discrepancy between verbal and performance scores, with the latter score higher (Verbal: Stanine 2 (low); Performance: Stanine 4 (low average)). On the Raven's Coloured Progressive Matrices, Lena's results were clearly above the mean.
Unit 14.1 History, hearing and cognitive evaluation
(1) Lena's history and clinical presentation are consistent with a diagnosis of specific language impairment (SLI). Which of the following features of her profile suggest a diagnosis of SLI?
(2) The history states that Lena experienced recurrent episodes of otitis media with effusion. What type of hearing loss might this have predisposed her to?
(3) Which feature of Lena's history indicates that her developmental problems are specific to language?
Language profile at 5;6 years
Lena underwent a wide-ranging assessment of her language skills at 5;6 years. Her repetition of sentences was poor. She seemed not to understand the sentences she was asked to repeat or to remember them. For example, when asked to repeat ‘I cycle around the big house every night’, she uttered ‘Cycle every house’ and ‘I cycle every house’. Her ability to repeat word lists was also compromised. When asked to repeat the list ‘mitten-bird-lamp’, she said ‘mitten-bird-chair’, and the repetition of ‘running-reading-swimming’ took the form ‘running-water-swim’. Lena relied heavily on visual feedback to help her discriminate phonemes. The following distinctions were problematic for her: /ɯ-y/, /ʃ-s/, /d-g/ and /b-p/. There were phonological problems in the use of liquids and consonant clusters. In terms of prosody, Lena exhibited ‘childish’ intonation due to too many sentence accents and exaggerated pitch variation. The retrieval of words from a given semantic category was difficult for her. For example, Lena was only able to produce two words in the food category (apple and banana), and when she was asked what kind of clothes she was wearing, she replied ‘shirt, braids, black and black [points to her trousers and shoes] and pink [points to a pink ribbon in her hair]. Lena could classify pictures of objects correctly, but was unable to provide a superordinate lexical item for semantic categories (e.g. clothes). Language comprehension was assessed to be at the 3- to 4-year level. Where no visual support was given, Lena's participation on tasks that required comprehension of logical–grammatical constructions was poor. There was poor comprehension of prepositions, and attributive, possessive and comparative constructions. In spontaneous speech, there were errors in the use of prepositions. The use of finiteness and correct word order was also problematic. No sentence connectors were used. Lena's narrative retelling was fragmentary. When new topics were introduced, she made inconsistent use of indefinite and definite articles to refer to them and overused deictic expressions.
Unit 14.2 Language profile at 5;6 years
(1) The repetition of word lists is problematic for Lena. Which of the following occurs during Lena's repetitions?
(2) Lena has difficulty with the production of consonant clusters. However, there is also evidence in her expressive output of the intact use of certain consonant clusters. Identify four such clusters.
(3) Lena has impaired lexical semantics. Are Lena's difficulties in this area of language largely expressive or receptive in nature? Provide evidence to support your answer.
(4) Lena is heavily dependent on visual cues to compensate for her poor language skills. Which two language levels are effectively compensated by the use of these cues?
(5) Lena produces ‘fragmentary’ narratives. Explain how this may be related to her lack of sentence connectors.
Language profile at 6;6 years
A second, comprehensive analysis of Lena's language was undertaken when she was 6;6 years. It was observed at this time that Lena had better understanding of instructions and that her echolalia was less evident. However, she still exhibited pragmatic problems and had difficulty concentrating on demanding tasks. Some of these problems were apparent in her responses to questions from the examiner (E).
Exchange 1
E: What would happen if you went out now without shoes?
L: You may go out in your shoes.
E: Yes, why?
L: You may not run and put on your shoes – may go out in the garden – then you get colours to play on – riding on horses.
Exchange 2
E: Why was her head aching? [Examiner shows a picture of a girl falling from a sledge]
L: Because she go in and ask with mother.
All tactile/kinaesthetic, visual/visuospatial, motor and non-verbal auditory tasks were performed adequately. Repetition of nonsense syllables, sequences with semantic content and tongue-twister words was poor. Sentence repetition was improved but still not age adequate. The repetition of word lists was also improved, with Lena retaining a maximum of three words. During narrative retelling, Lena related only three out of 10 events in the story, and even then not in a logical order. Since assessment at 5;6 years, Lena's phoneme discrimination had deteriorated, with eight distinctions now problematic for her. This necessitated a referral for an audiological examination where otitis media with effusion was confirmed. Three weeks later, when hearing was judged to be normal, the phoneme discrimination tasks were repeated. On this occasion, Lena failed on six distinctions. Unlike her assessment at 5;6 years, Lena was able to name all the clothes she was wearing. However, she was unable to give the names of clothes that were not present in the situation. Her comprehension of language was still not age adequate (4- to 5-year level), and she refused to undertake certain comprehension tasks. Her attempts to rhyme resulted in semantic errors (e.g. ‘eel’ was produced as a rhyme to ‘whale’), as did her attempts to name pictures (e.g. for ‘wheelchair’ she produced ‘old wagon bike’). Slight phonological problems still persisted. In terms of grammar, Lena occasionally omitted function words and she produced errors in the use of finiteness and prepositions during sentence repetition tasks and in spontaneous production. Sentence connectors were beginning to emerge.
Unit 14.3 Language profile at 6;6 years
(1) In exchanges 1 and 2, Lena is asked wh-questions which she clearly does not understand. Which of the following concepts must Lena possess in order to address these questions satisfactorily?
(2) In exchange 1, Lena's responses are clearly tangential to the questions she is asked. However, a certain type of script appears to dominate her responses. What is this script?
(3) Aside from its irrelevance, Lena's response in exchange 2 is problematic in three further respects. What are these respects?
(4) In unit 14.2, an explanation of Lena's ‘fragmentary’ narratives in terms of her lack of use of sentence connectors was considered. At 6;6 years, Lena is still experiencing difficulty with the production of narratives. Does the same explanation appear to account for her narrative difficulties at this age?
(5) In unit 14.2, visual cues were seen to compensate for certain of Lena's poor language skills. Is there any evidence of visual (or other) cues functioning in a compensatory role in the information provided above?
Language profile at 8;0 years
A third and final assessment of Lena's language skills was undertaken at 8;0 years. As the intelligibility of her speech improved, and her willingness to participate in dialogue increased, her conversational difficulties have become even more evident. She is eager to respond to the examiner and almost never refuses to answer. She is poorly oriented to her own person, place and time, and cannot say how many brothers and sisters she has or tell the time of day. Lena still does not engage with demanding tasks. Although the repetition of nonsense syllables is still problematic (Lena does not appear to understand what she should do), the repetition of sequences with semantic content is age appropriate. Lena can retain three words during the repetition of word lists but there can be interference from other lists or when new words are introduced. There are more omissions during the repetition of sentences than in spontaneous speech. During narrative retelling, Lena's own experience tends to dominate, with familiar people taking the role of actors in the story. This is evident in the following extract from a narrative retelling task:
E: What happened one morning in the summer?
L: My Misse and Murre [Lena's two cats] they could climb up the tree in their sharp claws.
Lena was able to remember the 10 events in the story when given questions. At this stage, there are no errors of phoneme discrimination. Lena still struggles to produce words within a given semantic category. However, she is now able to produce superordinate lexical items. There continues to be considerable difficulty with the comprehension of logical–grammatical constructions and there is still no ability to rhyme. There is good performance on the Token Test (De Renzi and Vignolo, Reference De Renzi and Vignolo1962), a test of language comprehension. Lena's naming is very poor for her age. Most naming errors are semantic in nature:
| Target word | Lena's production |
| pyramid | the kings |
| fern | heather |
| funnel | strainer |
| hasp | locked |
| sphinx | pyramid lion man |
There are still some grammatical problems such as the omission of function words and semantically inappropriate use of sentence adverbials and subjunctives. Lena's phonology has normalised. Her articulation sounds childish on account of a tendency to palatalise consonants, and her prosodic problems (e.g. exaggerated pitch variation) still persist.
Unit 14.4 Language profile at 8;0 years
(1) Lena's naming errors are interesting, with a range of associations linking her productions to the target word. What type of verbal behaviour is Lena exhibiting when she produces pyramid lion man for ‘sphinx’? Are there any other examples of this behaviour in the data in unit 14.3?
(2) During the production of narratives, Lena's own experience tends to dominate over the actors and events in the story. Why might this occur?
(3) Give one example of each of the following patterns in Lena's naming errors:
Focus on pragmatics
At 8;0 years, Lena participated in the following exchange with the examiner. The examiner is asking Lena a series of questions based on general knowledge:
E: What do you usually see on the ground when it is autumn?
L: Mosquitoes and birds and crows.
E: What season comes after autumn?
L: Winter and then spring then autumn and then spring…usually many days are passing.
E: What is it like in the winter?
E: Mm…and in the spring?
L: At day nursery when was winter then everybody went out and played and she throw snowballs on the wall and it was red.
E: But look, if I tell you that right now there are already some flowers outside and small, small buds on the trees and so on …
L: Flowers…on the apple trees I think are beautiful to see.
E: So what season is it when it is like this outside?
L: (pause) Mm …
E: Is it winter then?
L: No…spring! This is probably not spring (picks up a pen on the table). What sort of pen is this?
Unit 14.5 Focus on pragmatics
(1) Respond with true or false to each of the following statements:
(2) Lena makes use of topicalisation in the above exchange. Where does this occur? In view of Lena's language problems, what function might topicalisation serve for her?
(3) Does Lena display problems with world knowledge during this exchange with the examiner? Provide evidence to support your answer.
(4) Are there any referential anomalies in Lena's utterances in this exchange? Provide evidence in support of your answer.
(5) Give one example of each of the following in the above exchange:
