A longitudinal study of behavioral, emotional and social difficulties in individuals with a history of specific language impairment (SLI)
Introduction
Specific language impairment (SLI)1 is a developmental disorder involving significant language impairments in the context of normal nonverbal ability, hearing, and neurological status (Bishop, 1997, Leonard, 1998). The prevalence of SLI in young children has been estimated as 7% (Tomblin et al., 1997). It is thought that 40% of children identified with language impairments have persistent language difficulties (Law, Boyle, Harris, Harkness, & Nye, 2000), and some individuals continue to have language difficulties in adulthood (Clegg et al., 2005, Howlin et al., 2000). It is important to note, however, that people with SLI demonstrate considerable heterogeneity in their profiles of strengths and difficulties (Conti-Ramsden, 2008). Thus, research in this area includes participant pools that may not meet the traditional, verbal–nonverbal discrepancy definition of SLI. The present longitudinal study is no exception. However, we continue to use the term SLI in order to situate our findings within the research literature in this area with the acknowledgement that these individuals may or may not meet traditional SLI criteria continuously throughout development. For this reason, we refer to the participants in this study as having a history of SLI.
The term behavioral, emotional and social difficulties (BESD) is complex and clusters together a series of constructs related to aspects of young people's development. Each of these domains of functioning is distinct. Nonetheless, the term BESD can be a useful shorthand for providing a balanced coverage of a range of areas of functioning in young people, i.e., behaviors, emotions and relationships. It is widely recognized that children who have specific language impairment experience not only difficulties with language but also BESD. The co-occurrence of language impairments and BESD has been found in children with primary language difficulties (Beitchman et al., 1989, Cantwell et al., 1981, Lindsay et al., 2007) and also in children with primary psychiatric difficulties (Cohen et al., 1998, Gualtieri et al., 1983). Less is known, however, about the developmental trajectories of these difficulties. This study examines the longitudinal development of BESD in children with a history of SLI over a nine year time period and investigates how language and reading abilities relate to the developmental course of other difficulties.
Early work in this field focused on the prevalence of psychiatric disorders in children with SLI, in particular, behavioral difficulties (Baker and Cantwell, 1982, Beitchman et al., 1989). The general findings indicated that behavioral difficulties of the attention deficit and hyperactivity disorder (ADHD) type can co-occur with language difficulties. This has been supported by more recent findings of general attentional difficulties in individuals with SLI (Lum, Conti-Ramsden, & Lindell, 2007) as well as a higher prevalence of hyperactivity/attention behavioral difficulties among children with SLI when compared to children with typical language development (Benasich et al., 1993, Snowling et al., 2006). In terms of behavioral difficulties of the conduct type, recent studies have provided mixed evidence. Some investigations suggest higher levels of externalizing difficulties in childhood in individuals with SLI (Tomblin et al., 2000, van Daal et al., 2004) whilst others do not (Lindsay et al., 2007, Redmond and Rice, 1998, Redmond and Rice, 2002). For emotional problems, the research is scant and the available results are also not consistent. Some studies have found higher levels of internalizing difficulties in childhood (Coster et al., 1999, Redmond and Rice, 1998, Redmond and Rice, 2002) as well as in adolescence, in particular anxiety and depression (Conti-Ramsden & Botting, 2008). However, a number of studies have found little evidence of specific emotional problems in children with SLI (Snowling et al., 2006, Tomblin et al., 2000) or have found evidence when using particular methodologies, e.g., teacher report but not parental report (Redmond and Rice, 1998, Redmond and Rice, 2002).
A large body of literature points to the presence of social difficulties in children and adolescents with SLI (Benasich et al., 1993, Conti-Ramsden and Botting, 2004, Lindsay et al., 2007). Research suggests difficulties with social withdrawal. Children with SLI are more likely to play alone and exhibit symptoms of shyness (Fujiki, Brinton, Isaacson, & Summers, 2001). Some studies have reported shyness only for girls with SLI (Benasich et al., 1993, Tallal et al., 1989). There is more consistent evidence, however, of difficulties in peer relations (Fujiki et al., 1999, Gertner et al., 1994), poorer quality friendships (Durkin & Conti-Ramsden, 2007) and risk of victimization (Knox & Conti-Ramsden, 2007).
In sum, trends in the literature suggest that ADHD is likely to co-occur in individuals with SLI, at least in childhood. The evidence regarding conduct and emotional difficulties is less consistent. In respect of peer relations, children and adolescents with SLI appear to be disadvantaged. However, although a growing literature enriches our knowledge of BESD in SLI, different studies have examined different age groups and have included different measures, making comparisons across datasets difficult. Questions about the course of development are still to be addressed.
Longitudinal research has been limited, both in terms of scope and breadth of BESD measures used. Redmond and Rice (2002) found a decrease in emotional problems in children with SLI from 5 to 7 years of age, but also observed more stable patterns of attentional and social problems across this time period. Benasich and colleagues (1993) reported no developmental change from 4 to 8 years of age in an overall measure of behavior problems in children with SLI. Examining older children with SLI from 7 to 11 years of age, Silva, Williams and McGee (1987) found a decrease in an overall measure of BESD, as did Lindsay and colleagues (2007) for 8 to 12-year-olds with SLI. These data suggest that there may be a decrease in BESD in children with SLI from early to later childhood. In this sense, individuals with SLI may be similar to individuals with reading disabilities. Maughan and colleagues (1996) found decreasing attention and conduct problems from childhood to adolescence in their sample of reading disabled young people. The above data also raise the possibility that specific aspects of behavioral, emotional and social functioning may differ in their developmental trajectories.
In the existing literature, the account of the association between language impairments and BESD is somewhat limited and mixed, depending on the area of functioning being examined and the types of measures being used. Benasich et al. (1993) and Hart, Fujiki, Brinton, and Hart (2004) found no discernable relationship between language abilities and behavioral outcomes in childhood. However, Botting and Conti-Ramsden (2000) found more children with SLI over the clinical threshold for behavioral/social difficulties at ages 7 and 8 when they had language problems involving more than one linguistic modality. Snowling et al. (2006) also reported that a combined expressive and receptive language difficulty profile was related to social problems. Difficulties involving the expressive domain only were associated with attentional/hyperactivity problems. Similarly, Durkin and Conti-Ramsden (2007) found that receptive language at age 7 differentiated social outcomes in terms of good versus poor friendships at age 16. Overall language abilities have also been associated with behavioral difficulties (Lindsay et al., 2007), including attention/hyperactivity (Redmond & Rice, 2002). These studies raise the possibility that different aspects of language may be related to different areas of functioning in the behavioral, emotional and social domains (Beitchman, Brownlie, & Wilson, 1996). Lindsay et al. (2007) provide important additional evidence that measures of pragmatic abilities are linked to behavioral difficulties, though the use of an overall measure of BESD in that study means that the relationship to specific areas of functioning remains to be investigated.
Problems with reading have also been linked with BESD (Maughan et al., 1996). In particular, reading difficulties have been associated with behavioral problems in childhood in both the attention/hyperactivity and conduct domains (Frick et al., 1991, Maughan et al., 1996). Interestingly, individuals with SLI often exhibit impairments in reading (Bishop and Adams, 1990, Botting et al., 2006, Snowling et al., 2000). However, research examining the association between reading impairments and BESD in individuals with SLI is only just emerging. The evidence so far suggests that reading difficulties in SLI are related to behavioral problems, particularly of the attention/hyperactivity and conduct types, but not to emotional difficulties (Tomblin et al., 2000).
Although there are several studies pointing to the presence of BESD in individuals with SLI, much less is known of the developmental trajectories of their difficulties. To our knowledge, this study is the first to investigate BESD in individuals with SLI from childhood to adolescence and their relation to language and reading abilities. We included a global measure of BESD and investigated four specific domains of functioning: two domains related to behavioral difficulties, i.e., hyperactivity and conduct, as well as emotional problems and difficulties with peer relations. Based on the previous literature, we expected to find a decrease in overall BESD across time. In terms of specific areas of functioning, a basis for predictions was less clear. We anticipated we were likely to discover differences in the developmental trajectories of specific areas of functioning, with the literature suggesting peer relations as particularly problematic for individuals with SLI. We also aimed to investigate the developmental relationships between language abilities and BESD and between reading abilities and BESD. We examined three aspects of language – expressive, receptive and pragmatic abilities – as well as reading accuracy.
Section snippets
Participants
The participants were individuals with a history of SLI who took part in the Manchester Language Study (Conti-Ramsden and Botting, 1999a, Conti-Ramsden and Botting, 1999b, Conti-Ramsden et al., 1997). The original cohort of 242 children represented a random 50% sample of all children attending year 2 (age 7) in language units across England. Language units are usually attached to mainstream schools. They are specialized classrooms set up to support children with primary language difficulties.
BESD developmental trajectories in SLI
The total difficulties score as well as all subscales were analyzed longitudinally to determine whether BESD increased or decreased in individuals with SLI from childhood to adolescence. All analyses were carried out in terms of linear and quadratic trends, and if the trends were significant or marginally significant, also categorically (testing directly the different age periods). Marginal significance in the overall trends are reported, but for the categorical analyses only significant
Development of BESD in SLI: from childhood to adolescence
This investigation examined the developmental trajectories of BESD in individuals with a history of SLI. In light of previous research findings, we expected that overall BESD would decrease from childhood to adolescence. This was not borne out; the global measure of total difficulties decreased from age 7 to age 16, but was not statistically significant. However, this lack of a significant difference in the overall measure may have been due to the distinct developmental trajectories observed
Acknowledgements
The authors acknowledge the Economic and Social Research Council Fellowship (RES-063-27-0066) awarded to the corresponding author and the support of the Nuffield Foundation (AT251 [OD], DIR/28, and EDU 8366) which facilitated the data collection. We thank the research assistants and Zoë Simkin for assisting in data collection and organisation. We would also like to thank Alessandra Iervolino, Barbara Maughan, Robert Goodman, and Stephan Collishaw for use of the Rutter B-scale/SDQ calibration
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