Pragmatic Disorders in Complex and Underserved Populations

Abstract

Not all pragmatic disorders have received the level of clinical study of the populations examined in Chap. 2. While the pragmatic impairments of clients with right-hemisphere damage or traumatic brain injury are well characterized, relatively little is known about the pragmatic language skills of children with emotional and behavioural disorders or adults with non-Alzheimer’s dementias. These children and adults belong to ‘complex’ populations by virtue of the fact that their pragmatic disturbance occurs in the presence of significant psychiatric and cognitive disorders. Similarly, certain groups of clients with pragmatic impairments are beyond the reach of, or are overlooked by, clinical language services. These groups include adolescents in juvenile detention facilities and adults in prison. These clients belong to an ‘underserved’ population to the extent that their language needs are inadequately assessed and treated. Although these different clients have not been the focus of extensive academic research or clinical services to date, it is clear that an array of factors means complex and underserved populations are likely to become an increasingly important part of the caseload of speech and language therapists in years to come. These factors include the growing health burden of diseases such as dementia and the considerable economic and social costs of criminal behaviour. The search for effective ways to address these problems means that an examination of the pragmatic impairments of clients in these various populations is particularly timely.

Notes

• 1. Brauner and Stephens (2006, p. 304) state that ‘[e]stimating the prevalence of emotional/behavioral disorders in children is critical to providing the mental health services they need. This is extremely difficult, however, given the lack of a “standard” and correct inclusive definition for a minimum functional level of impairment in some or all domains for an agreed-upon duration’.

• 2. In an earlier study of 78 female juvenile delinquents in a correctional facility, Sanger et al. (2000) reported that 17 (22 %) were candidates for language services. However, none of these girls had received language services. Similar findings were reported in a subsequent study of 67 female adolescent delinquents (Sanger et al. 2001). Thirteen girls (19.4 %) performed sufficiently poorly on language assessments to qualify for language services. Although six (46.15 %) of these thirteen subjects had received special education services, none of these six had received services for speech and language.

• 3. In a study of 13 female adolescents who resided in a correctional facility, Sanger et al. (2003, p. 481) reported that issues relating to poor communication with others and low self-worth emerged during interviews conducted with these girls. One teenager described communication with her friends in the following terms: ‘In our group no one wants to listen what the other person has to say. She’s telling me something and I don’t want to hear it. I’ll just start talking faster’.

• 4. Snow and Powell (2008: 16) state that ‘[p]oor academic performance in turn carries the risk of early school departure, inadequate further education and training, chronic unemployment and dependence on welfare and/or continued criminal activity’.

• 5. Jones et al. (2007) reported social cognitive deficits—specifically, a failure to recognize the facial expression of anger—in the male young offenders in their study. ToM deficits have also been reported in child sex offenders (Elsegood and Duff 2010). Additionally, several clinical conditions, in which ToM deficits are found, tend to be over-represented in the criminal justice system. These conditions include schizophrenia, autism spectrum disorder and antisocial personality disorder. (Cashin and Newman 2009; Dolan and Fullam 2004; Haskins and Silva 2006; Rautanen and Lauerma 2011).

• 6. The prevalence of Parkinson’s disease increases with age. In a study of a general elderly population in the Netherlands, de Rijk et al. (1995) reported the following prevalence figures for different age groups: 0.3 % (55–64 years), 1.0 % (65–74 years), 3.1 % (75–84 years), 4.3 % (85–94 years). As people live longer, it is to be expected that that the number of PD cases, and dementia cases related to PD, will also increase.

• 7. As HIV drug therapies improve and become more widely accessible, the number of people living with HIV infection (HIV prevalence) will increase. Dementia is one of the neurological complications of HIV infection. It might therefore be expected that the number of cases of HIV-associated dementia (HAD) will also increase. However, alongside the marked increase in survival rates of HIV-infected persons since the introduction in 1996 of combination antiretroviral therapies (Woods et al. 2009), there has also been a large decrease in the number of cases of HAD as a direct consequence of these therapies (Vivithanaporn et al. 2011).

• 8. Dementia is one of the clinical features of vCJD, a recently identified form of CJD that has been caused by the transmission of BSE in cattle to humans. A study which attempted to estimate the number of people who are incubating this disease suggests that vCJD will become a more significant cause of dementia in years to come. Hilton et al. (2004) tested samples of appendix and tonsil tissue from 16,703 patients for the accumulation of prion protein, which is believed to be indicative of vCJD. From the tissues identified as containing prion protein, an estimated prevalence of 237 per million was calculated. This is equivalent to 1 person in 4,219 population believed to be incubating vCJD.

• 9. An example of how the narratives of these patients lacked global connectedness can be seen in the following description of one of the scenes in the story. The patient with FTD who produced this extract failed to make any connection between one of the two frogs in the scene and the frog that escaped from the jar at the start of the story (Ash et al. 2006, p. 1409):

• Dog—or boy’s.. over log

• Dog’s over the log too

• Um … they’re on the log

• See two frogs

• See the mom and … dad and a mom frog

• And you got one, two, three, four, five .. seven little—eight little toads.

• 10. Perkins et al. (1998, p. 33) state that ‘research into pragmatic behaviour has primarily been carried out through the analysis of the ability of the person with dementia to produce different forms of discourse, including picture description, story telling, procedural discourse and clinical interviews’.