Journal of Communication Disorders


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Journal of Communication Disorders

  1. 1. Journal of Communication Disorders 44 (2011) 186–199 Contents lists available at ScienceDirect Journal of Communication DisordersA longitudinal study of behavioral, emotional and social difficulties inindividuals with a history of specific language impairment (SLI)Michelle C. St Clair a, Andrew Pickles b, Kevin Durkin c, Gina Conti-Ramsden a,*a School of Psychological Sciences, Ellen Wilkinson Building, University of Manchester, Oxford Road, Manchester M13 9PL, UKb School of Medicine, University Place, University of Manchester, Oxford Road, Manchester M13 9PL, UKc Department of Psychology, University of Strathclyde, Glasgow G1 1QE, Scotland, UKA R T I C L E I N F O A B S T R A C TArticle history: Children with specific language impairment (SLI) have often been reported to haveReceived 11 February 2010 associated behavioral, emotional and social difficulties. Most previous studies involveReceived in revised form 20 July 2010 observations at a single time point, or cross sectional designs, and longitudinal evidence ofAccepted 3 September 2010 the developmental trajectories of particular difficulties is limited. The Strengths andAvailable online 1 October 2010 Difficulties Questionnaire was used to measure behavioral (hyperactivity and conduct), emotional and social (peer) problems in a sample of individuals with a history of SLI at fourKeywords: time points from childhood (age 7) to adolescence (age 16). A decrease in behavioral andSpecific language impairment (SLI)Developmental trajectories emotional problems was observed from childhood to adolescence, although emotionalBehavioral, emotional and social difficulties problems were still evident in adolescence. In contrast, there was an increase in social(BESD) problems. Reading skills and expressive language were related only to behavioralLanguage and reading skills problems. Pragmatic abilities were related to behavioral, emotional and social difficulties. As a group, those with a history of SLI have poorer long term social and, to a lesser extent, emotional outcomes. In contrast, behavioral difficulties appear to decrease to normative levels by adolescence. Different aspects of early language abilities and reading skills exert different types and degrees of influence on behavioral, emotional and social difficulties. Learning outcomes: Readers will be able to: (1) understand the types of behavioral, emotional and social difficulties present in individuals with a history of SLI; (2) be familiar with the developmental trajectory of these difficulties from childhood to adolescence; and (3) understand the relationships between behavioral, emotional and social difficulties and early language and literacy ability. ß 2010 Elsevier Inc. All rights reserved.1. Introduction Specific language impairment (SLI)1 is a developmental disorder involving significant language impairments in thecontext of normal nonverbal ability, hearing, and neurological status (Bishop, 1997; Leonard, 1998). The prevalence of SLI inyoung children has been estimated as 7% (Tomblin et al., 1997). It is thought that 40% of children identified with languageimpairments have persistent language difficulties (Law, Boyle, Harris, Harkness, & Nye, 2000), and some individuals continueto have language difficulties in adulthood (Clegg, Hollis, Mawhood, & Rutter, 2005; Howlin, Mawhood, & Rutter, 2000). It is * Corresponding author. Tel.: +44 0161 275 3514; fax: +44 0161 275 3965. E-mail addresses: (M.C. St Clair), (A. Pickles), Durkin), (G. Conti-Ramsden). 1 Specific language impairment (SLI); Behavioral, emotional and social difficulties (BESD); Attention Deficit and Hyperactivity Disorder (ADHD);Strengths and Difficulties Questionnaire (SDQ).0021-9924/$ – see front matter ß 2010 Elsevier Inc. All rights reserved.doi:10.1016/j.jcomdis.2010.09.004
  2. 2. M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199 187important to note, however, that people with SLI demonstrate considerable heterogeneity in their profiles of strengths anddifficulties (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 usethe term SLI in order to situate our findings within the research literature in this area with the acknowledgement that theseindividuals may or may not meet traditional SLI criteria continuously throughout development. For this reason, we refer tothe 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 constructsrelated to aspects of young people’s development. Each of these domains of functioning is distinct. Nonetheless, the termBESD 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 impairmentexperience not only difficulties with language but also BESD. The co-occurrence of language impairments and BESD has beenfound in children with primary language difficulties (Beitchman, Hood, Rochon, & Peterson, 1989; Cantwell, Baker, &Mattison, 1981; Lindsay, Dockrell, & Strand, 2007) and also in children with primary psychiatric difficulties (Cohen et al.,1998; Gualtieri, Koriath, Van Bourgondien, & Saleeby, 1983). Less is known, however, about the developmental trajectories ofthese difficulties. This study examines the longitudinal development of BESD in children with a history of SLI over a nine yeartime period and investigates how language and reading abilities relate to the developmental course of other difficulties.1.1. SLI and BESD Early work in this field focused on the prevalence of psychiatric disorders in children with SLI, in particular, behavioraldifficulties (Baker & Cantwell, 1982; Beitchman et al., 1989). The general findings indicated that behavioral difficulties of theattention deficit and hyperactivity disorder (ADHD) type can co-occur with language difficulties. This has been supported bymore recent findings of general attentional difficulties in individuals with SLI (Lum, Conti-Ramsden, & Lindell, 2007) as wellas a higher prevalence of hyperactivity/attention behavioral difficulties among children with SLI when compared to childrenwith typical language development (Benasich, Curtiss, & Tallal, 1993; Snowling, Bishop, Stothard, Chipchase, & Kaplan,2006). In terms of behavioral difficulties of the conduct type, recent studies have provided mixed evidence. Someinvestigations suggest higher levels of externalizing difficulties in childhood in individuals with SLI (Tomblin, Zhang,Buckwalter, & Catts, 2000; van Daal, Verhoeven, & van Balkom, 2004) whilst others do not (Lindsay et al., 2007; Redmond &Rice, 1998, 2002). For emotional problems, the research is scant and the available results are also not consistent. Somestudies have found higher levels of internalizing difficulties in childhood (Coster, Goorhuis-Brouwer, Nakken, & LutjeSpelberg, 1999; Redmond & Rice, 1998, 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 reportbut not parental report (Redmond & Rice, 1998, 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 & Botting, 2004; Lindsay et al., 2007). Research suggests difficulties with social withdrawal. Childrenwith SLI are more likely to play alone and exhibit symptoms of shyness (Fujiki, Brinton, Isaacson, & Summers, 2001). Somestudies have reported shyness only for girls with SLI (Benasich et al., 1993; Tallal, Dukette, & Curtiss, 1989). There is moreconsistent evidence, however, of difficulties in peer relations (Fujiki, Brinton, Morgan, & Hart, 1999; Gertner, Rice, & Hadley,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. Theevidence regarding conduct and emotional difficulties is less consistent. In respect of peer relations, children and adolescentswith SLI appear to be disadvantaged. However, although a growing literature enriches our knowledge of BESD in SLI, differentstudies have examined different age groups and have included different measures, making comparisons across datasetsdifficult. 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 stablepatterns of attentional and social problems across this time period. Benasich and colleagues (1993) reported nodevelopmental change from 4 to 8 years of age in an overall measure of behavior problems in children with SLI. Examiningolder children with SLI from 7 to 11 years of age, Silva, Williams and McGee (1987) found a decrease in an overall measure ofBESD, as did Lindsay and colleagues (2007) for 8 to 12-year-olds with SLI. These data suggest that there may be a decrease inBESD in children with SLI from early to later childhood. In this sense, individuals with SLI may be similar to individuals withreading disabilities. Maughan and colleagues (1996) found decreasing attention and conduct problems from childhood toadolescence in their sample of reading disabled young people. The above data also raise the possibility that specific aspects ofbehavioral, emotional and social functioning may differ in their developmental trajectories.1.2. BESD and its relation to language and reading impairments In the existing literature, the account of the association between language impairments and BESD is somewhat limitedand 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
  3. 3. 188 M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199behavioral outcomes in childhood. However, Botting and Conti-Ramsden (2000) found more children with SLI over theclinical threshold for behavioral/social difficulties at ages 7 and 8 when they had language problems involving more than onelinguistic modality. Snowling et al. (2006) also reported that a combined expressive and receptive language difficulty profilewas 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 differentiatedsocial outcomes in terms of good versus poor friendships at age 16. Overall language abilities have also been associated withbehavioral difficulties (Lindsay et al., 2007), including attention/hyperactivity (Redmond & Rice, 2002). These studies raisethe possibility that different aspects of language may be related to different areas of functioning in the behavioral, emotionaland social domains (Beitchman, Brownlie, & Wilson, 1996). Lindsay et al. (2007) provide important additional evidence thatmeasures of pragmatic abilities are linked to behavioral difficulties, though the use of an overall measure of BESD in thatstudy 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 havebeen 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 & Adams, 1990;Botting, Simkin, & Conti-Ramsden, 2006; Snowling, Bishop, & Stothard, 2000). However, research examining the associationbetween reading impairments and BESD in individuals with SLI is only just emerging. The evidence so far suggests thatreading 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).1.3. The present study Although there are several studies pointing to the presence of BESD in individuals with SLI, much less is known of thedevelopmental trajectories of their difficulties. To our knowledge, this study is the first to investigate BESD in individualswith SLI from childhood to adolescence and their relation to language and reading abilities. We included a global measureof 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 previousliterature, we expected to find a decrease in overall BESD across time. In terms of specific areas of functioning, a basis forpredictions was less clear. We anticipated we were likely to discover differences in the developmental trajectories ofspecific areas of functioning, with the literature suggesting peer relations as particularly problematic for individuals withSLI. We also aimed to investigate the developmental relationships between language abilities and BESD and betweenreading abilities and BESD. We examined three aspects of language – expressive, receptive and pragmatic abilities – as wellas reading accuracy.2. Method2.1. Participants The participants were individuals with a history of SLI who took part in the Manchester Language Study (Conti-Ramsden& Botting, 1999a, 1999b; Conti-Ramsden, Crutchley, & Botting, 1997). The original cohort of 242 children represented arandom 50% sample of all children attending year 2 (age 7) in language units across England. Language units are usuallyattached to mainstream schools. They are specialized classrooms set up to support children with primary languagedifficulties. Children reported by teachers to have frank neurological difficulties, diagnoses of autism, known hearingimpairment or general learning impairments were excluded. All children had English as a first language, but 12% hadexposure to languages other than English at home. Informed consent was gained from all participants. This study includes234 children from the initial study cohort aged 6;5 to 7;9 years (females: 23.5%) with reassessments at age 8 (n = 203), 11(n = 167), and 16 (n = 103). The attrition observed was partly due to funding constraints at follow-up stages of the study.There was no difference in either age 7 receptive or expressive language abilities between those who participated at 16 andthose who did not participate, ps > .8. However, given that the number of participants varied at the different time pointsassessed, it was necessary to take this into consideration in our longitudinal analyses. Thus, we employed statistical modelsthat account for participant attrition. The method used accounts for bias due to attrition on an assumption that losses may beselective of individuals with higher or lower observed measures but does not allow additional selective loss associated withthe unobserved measures (Missing at Random). Summary of the language skills in these children at age 7, 8, 11, and 16 isdisplayed in Table 1. Performance IQ (PIQ) at age 7 (Coloured Progressive Matrices; Raven, 1986) was within the normal range, M = 105.98,SD = 14.89. PIQ was not found to be related to the SDQ total difficulties score, nor any of the subscales, ps > .1. In addition,parental income and maternal education at age 16 were analyzed with regard to the SDQ total difficulties and the foursubscales. There were no differences between the four levels of parental income (<£10,401, £10,401–£20,800, £20,801–£36,400, and >£36,401; at 2003–2005 income levels) neither for the SDQ total difficulties score nor for any of the subscales,ps > .05. There were also no differences between the three levels of maternal education (no qualification, basic educationalqualification [GCSE/O-level to some college education] and higher education [university degree/postgraduate]) for the SDQtotal score or for any of the subscales, p > .3.
  4. 4. M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199 189Table 1Average expressive and receptive language abilities at ages 7, 8, 11 and 16. 7 8 11 16a b Expressive language 83.79 (10.48) 83.94 (11.31) 73.64 (11.56) 72. 71 (10.52) Receptive languagec 83.74 (10.95) 85.98 (12.04) 86.55 (15.62) 82.33 (16.30) a The age 16 data contain a subset of individuals tested at age 14; funding constraints only allowed psycholinguistic tests to be conducted at age 16 ifthere were no data available from an additional age 14 follow-up that is not reported in this study. b Expressive language measures: ages 7 and 8 – Bus Story (Renfrew, 1991), ages 11 and 16 – Clinical Evaluation of Language Fundamentals-Revised(CELF-R) Recalling Sentences subtest (Semel et al., 1987). c Receptive language measures: ages 7, 8 and 11 – TROG (Bishop, 1982), age 16 – CELF-R Word Classes subtest. Though all children attended language units at age 7, 15.5% (31) transferred to mainstream school with no support at age 8and a further 13.5% (27) transferred to mainstream school with support at age 8. However, 64.0% (128) either stayed in the samelanguage unit or transferred to another similar language unit. A minority of children (6.5% or 13 children) were enrolled inspecial units or schools. There was no information available for three of the children. At age 11, 13% (21) of the sample was inmainstream education without support with a further 51% (82) with support. Only 11.1% (18) remained in language units while4.3% (7) were placed in language schools. An additional 18.5% (30) were placed in special schools and 2.5% (4) were held back inprimary school. There was no information available for the remaining 5 children at age 11. At age 16, 16.5% (17) were inmainstream school with no support while 51.5% (53) were in mainstream with support. Language units were attended by 1.9%(2) and language schools by 3.9% (4). Additionally, 4.9% (5) attended a special unit while 21.4% (22) attended a special school.2.2. Measures The Strengths and Difficulties Questionnaire (SDQ) teacher report version was used to measure BESD (Goodman, 1997).Given the changing nature of teachers’ relationships with students from primary to secondary school, the potential forunder-reporting by secondary school teachers was investigated. Our results indicate this was not the case and furthermore,there was comparability between teacher-report and self-report versions of the SDQ (see Appendix A). The SDQ includes a total difficulties score as well as four subscales measuring behavioral (hyperactivity and conduct),emotional and social (peer relations) difficulties. The SDQ scores at ages 7 and 8 were calibrated using multiple imputationfrom the Rutter Behavioural Questionnaire (Rutter, 1967). Full details of this procedure can be found in Appendix B. The SDQ has a cutoff of 12 on the total difficulties score, as this was the best clinical indicator of psychiatric difficulties(Goodman, 1999). The clinical cutoffs for the individual subscales on the teacher version (6, 3, 5 and 4 or above for thehyperactivity, conduct, emotional and peer subscales, respectively) indicated that 80% of children from a community samplewere considered normal, leaving 20% scoring over the cutoff. These ranged between borderline and abnormal (Goodman,1997). In the present study, we combine those who score in the borderline or abnormal range as ‘‘impaired’’. Language measures at age 7 and 11 were used. At age 7, expressive language was measured with the Bus Story (Renfrew,1991). The Test of Reception of Grammar (TROG; Bishop, 1982) was used to measure receptive language at age 7. At age 11,the teachers completed the pragmatic scale of the Children’s Communication Checklist (CCC; Bishop, 1998). High scores (132or above) on this scale indicate no pragmatic problems; scores below 132 indicate pragmatic impairment. Reading measures at age 7 were also used in the analyses. Participants completed the word reading subtest of the BritishAbilities Scale (BAS; Elliot, 1983), a measure of single word reading. The Bus Story, TROG and BAS word reading raw scoreswere translated to a percentile rank based on the published population norms and then converted to standard scores (with amean of 100 and standard deviation of 15) for comparison purposes.2.3. Statistical analyses The statistical program Stata/SE (StataCorp, 2007) was utilized for all statistical analyses. Participant gender was acovariate in all analyses. Because SDQ subscale scores are highly skewed, for formal inference they were analyzed as ordinalvariables using the Generalized Linear Latent and Mixed Models procedure— (Rabe-Hesketh, Skrondal, &Pickles, 2002). Graphs of trends in cohort mean scores were compiled from fitted values from a multilevel mixed-effectslinear regression model. In all analyses, the non-independence and attrition of the longitudinal data were accounted forunder an assumption of missing at random. Results from the imputed datasets were combined using Rubin’s rule. To controlfor multiple comparisons, the significance level was set to the .01 level. However, for interest, we report results as marginalwhen alpha varied between 0.01 and 0.05 for the main findings. Full details of these analyses are given in Appendix C.3. Results3.1. BESD developmental trajectories in SLI The total difficulties score as well as all subscales were analyzed longitudinally to determine whether BESD increased ordecreased in individuals with SLI from childhood to adolescence. All analyses were carried out in terms of linear and
  5. 5. [()TD$FIG]190 M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199Figure 1. Developmental trajectories of the mean SDQ total difficulties score and all subscale scores with standard error of the mean bars. The clinical cutoffline (solid) and a line showing the mean for the normative sample (Ages 5–10 Normative Sample Means (SD): SDQ total – 6.7 (5.9); Hyperactivity – 3.0 (2.8);Conduct – 0.9 (1.6); Emotional – 1.5 (1.9); Peer – 1.4 (1.8). Ages 11–15 Normative Sample Means (SD): SDQ total – 6.3 (6.1); Hyperactivity – 2.6 (2.7);Conduct – 0.9 (1.7); Emotional – 1.3 (1.9); Peer – 1.4 (1.8)) aged 5–15 years old (dotted) are included for reference. All scores are fitted values to account forattrition over time.quadratic trends, and if the trends were significant or marginally significant, also categorically (testing directly the differentage periods). Marginal significance in the overall trends are reported, but for the categorical analyses only significantdifferences are reported for ease of reading with one exception where their inclusion clarifies the findings. As there were noquadratic trends in the data, only the linear and categorical models are discussed. An age by gender interaction term was alsoincluded in all longitudinal analyses, but the interaction was not found to be significant, indicating that the longitudinaltrends were consistent for male and female individuals with SLI. See Fig. 1 for graphical representation of the developmentaltrajectories and Table 2 for means and standard deviations. The linear trend for the SDQ total difficulties score was not significant, b = À.05, CI = À.10 to À.001, p = .06. However, therewere significant differences in several of the subscales of the SDQ. There was a significant linear trend in the hyperactivity subscale, b = À.08, CI = À.13 to À.03, p < .005, indicating fewerhyperactivity difficulties over time. There were significantly fewer hyperactivity difficulties at age 16 than at 7 and 8 years,b = À.67, CI = À1.14 to À.19, p < .01 and b = À.71, CI = À1.24 to À.18, p < .01, respectively. A significant linear trend in the conduct subscale, b = À.14, CI = À.20 to À.07, p < .001, indicated fewer problems overtime. When tested categorically, significantly fewer conduct problems occurred at age 16 than at ages 7 and 8, b = À1.13,Table 2Mean (and SD) SDQ total difficulties and subscale scores including percentage of individuals with a history of SLI who scored over the impairment thresholdat age 7, 8, 11 and 16. The expected mean levels of difficulty and the expected percentages of impaired individuals are given as a reference. Total difficulties Hyperactivity Conduct Emotional Peer Score Impaired Score Impaired Score Impaired Score Impaired Score Impaired 7 11.05 (7.01) 42.1% 4.18 (2.95) 33.1% 1.76 (1.95) 26.0% 2.96 (2.68) 26.6% 2.14 (2.20) 23.0% 8 11.79 (7.02) 46.0% 4.16 (2.89) 31.6% 1.71 (2.00) 23.9% 3.48 (2.73) 34.1% 2.44 (2.24) 28.0% 11 10.72 (5.86) 38.3% 3.89 (2.51) 27.2% 1.36 (2.00) 21.0% 2.64 (2.14) 15.5% 2.79 (2.30) 32.7% 16 9.62 (6.51) 34.0% 3.35 (2.80) 20.6% 0.92 (1.53) 17.5% 2.45 (2.35) 20.8% 2.92 (2.39) 38.7% Expectedy 7.20 (6.06) 20.0% 3.32 (2.83) 20.0% 1.06 (1.68) 20.0% 1.40 (1.90) 20.0% 1.43 (1.83) 20.0% y Population normative expected mean levels from Meltzer et al. (2000), adjusted for our gender distribution. This expected level appears relatively stableacross development.
  6. 6. M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199 191CI = À1.71 to À.56, p < .001 and b = À1.09, CI = À1.77 to À.42, p < .005. In addition, difficulties reported at age 11 were fewerthan those reported at age 7, b = À.66, CI = À1.15 to À.16, p < .01. There was a marginally significant linear trend in the emotional subscale, b = À.06, CI = À.11 to À.01, p = .01, in thatgenerally there were fewer emotional problems over time. When tested categorically, it was found that at age 16 the SLIsample had significantly fewer emotional problems than at 8 years, b = À.77, CI = À1.29 to À.25, p < .005. In contrast, a significant linear trend in the peer subscale, b = .09, CI = .02 to .15, p < .01, indicated an increase in peerproblems over time. The categorical differences showed no significant effects between ages 7, 8, 11 and 16, ps > .01 (therewere marginal increases in peer problems from age 7 to ages 11 and 16, b = .64, CI = .11 to 1.16, p = .02 and b = .72, CI = .17–1.27, p = .01), indicating that the increase in peer problems over the nine year time span was gradual. It is important to note the mean scores for all the SDQ scores fell below what is considered to be a clinical level ofdifficulty. Table 2 presents the proportion of children at each age point that exceeded the clinical thresholds. Variation wasobserved in the proportion of individuals who scored above the impairment threshold for each domain. There was evidenceof a decrease in the proportion of impaired individuals for behavioral and emotional problems whilst the opposite patternwas observed for social difficulties as indexed by the peer subscale. Longitudinal analysis using these proportions revealedthe same pattern of findings as described above.3.2. Developmental trajectories: robustness of the findings Although attrition was accounted for in the analysis, we conducted further analyses including the subsample ofindividuals who had SDQ measures at all 4 timepoints (N = 73) and the subsample of individuals who had SDQ measuresfor 3 out of the 4 timepoints (N = 166). This was done to provide further evidence that the longitudinal results of thestudy (with all participants at each timepoint) were robust. The significant longitudinal results (linear and categoricaldifferences) were replicated (at either the .01 or .05 level) when entering only the individuals who had three of the fourtimepoints available. The one instance that did not reach significance in the three out of four timepoints analysisbecame significant in the more stringent replication requiring all four timepoints (categorical 7–11 difference conductsubscale). With regard to the replication requiring all four timepoints, the patterns of results were replicated, but someresults found to be significant in the full longitudinal analysis reported above did not meet the .05 level of significancein this smaller sample (linear trend emotional subscale p = .10; linear trend peer subscale, p = .07; categorical 8–16difference hyperactivity subscale, p = .08; categorical 8–16 difference emotion subscale, p = .13). This is perhaps notsurprising, as the difference in power from 234 to 73 individuals is substantial. In all of these cases, the 3 out of 4timepoints analysis returned significant results at the .05 level. Thus, we are confident that the analyses involving allparticipants available at each time point reported in the main results of the study are representative of the developmentof individuals with a history of language impairment and are not influenced by attrition or sampling differences atdifferent timepoints. The above results provide further evidence that the longitudinal analyses reported in Section 3.1 are robust. The generalpattern of results indicates there was a reduction of behavioral and emotional problems over time, i.e. there were moredifficulties earlier in development. In contrast, data on the peer subscale revealed increasing social difficulties fromchildhood to adolescence.3.3. Language ability, reading ability and BESD The earliest measure available for each aspect of language and literacy examined was used, i.e., reading accuracy,expressive and receptive language at age 7 and pragmatic abilities at age 11. We examined the relationship between theearly language and reading measures and the SDQ scores (total and subscales, respectively) at each of the age points (i.e., therelationship between language ability at age 7 and SDQ at age 7, then between language at age 7 and SDQ at age 8, and so on).For pragmatic abilities, we examined the relationship between these abilities and BESD at 11 and 16 years only. Previousresearch investigating the longitudinal trajectories of both language and literacy skills has found that these abilities arerelatively stable. From ages 7 to 16 years, there is not much evidence of catch-up by individuals with a history of SLI inrelation to same age peers (Conti-Ramsden, St Clair, Pickles, & Durkin, under review; St Clair, Durkin, Conti-Ramsden, &Pickles, 2010). Thus, using the earliest measure of language and literacy abilities is likely to give an indication of overallability throughout the nine year time span studied. The continuous line in Fig. 2 and subsequent figures represents the average across all age points, i.e., the average linearrelationship between a particular skill and BESD. These are prediction plots based on the raw data, not fitted values, thus thecurvature of the trajectories may be more influenced by individual data points. Expressive language had a marginal effect onthe SDQ total difficulties score, b = À.02, CI = À.04 to À.003, p = .02, as well as the hyperactivity, b = À.02, CI = À.04 to À.004,p = .02, and conduct subscales, b = À.03, CI = À.05 to À.003, p = .03. In all cases, lower expressive language ability was relatedto more behavioral problems, as can be seen in Fig. 2. Expressive language was not predictive of the outcomes on theemotional or peer subscales, ps > .2. Fig. 3 presents the prediction plot for the relationship between pragmatic language and BESD. Pragmatic language had asignificant linear association with the total difficulties score, as well as the hyperactivity, conduct, emotional and peersubscales, b = À.06, CI = À.08 to À.04, p < .001 for SDQ total score; b = À.04, CI = À.06 to À.01, p < .01 for the hyperactivity
  7. 7. [()TD$FIG]192 M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199Fig. 2. SDQ total difficulties score and all subscale scores by age 7 expressive language ability for all ages (solid line) and separated into age 7, 8, 11 and 16predictive trajectories.[()TD$FIG]Fig. 3. SDQ total difficulties score and all subscale scores by age 11 pragmatic language ability for all ages (solid line) and separated into age 11 and 16predictive trajectories.
  8. 8. [()TD$FIG] M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199 193Fig. 4. SDQ total difficulties score and all subscale scores by age 7 receptive language abilities for all ages (solid line) and separated into age 7, 8, 11 and 16predictive trajectories.subscale; b = À.05, CI = À.09 to À.02, p < .005 for the conduct subscale; b = À.03, CI = À.05 to À.01, p < .01 for the emotionalsubscale; and b = À.06, CI = À.09 to À.04, p < .001 for the peer subscale. As can be seen in Fig. 3, lower pragmatic abilitieswere related to elevated levels in BESD in a roughly linear fashion, although this was less obvious for the hyperactivity scale.Early receptive language ability did not appear to influence the total difficulties score or any of the four SDQ subscales in alinear fashion, ps > .07 (see Fig. 4). Although the figures show some variability in the prediction trajectories based on the time points, it is striking that thetrajectories, for the most part, maintain the same relationship throughout the nine year time frame. The expectationwould be that concurrent relationships would be stronger than distant ones. We tested this by using a language ability byage interaction term which was added to a model that included main effects of language ability, age, and the usualcovariate of gender along with a gender by age interaction term as predictors. If the effect of language ability on BESDdiffered across time, we would expect a significant difference in the language ability by age interaction term. Theseanalyses were carried out separately for each BESD measure and for each type of language skill examined. For the SDQtotal difficulties score and all subscales the language ability by age interaction terms were non-significant for receptive,expressive, and pragmatic language, ps > .02.2 This suggested that expressive language, receptive language andpragmatic abilities maintained a consistent relationship with behavioral, emotional and social difficulties throughout thedevelopmental period examined. Fig. 5 shows the relationships between the SDQ scores and the earliest measure of reading accuracy. There was asignificant effect of reading accuracy on the hyperactivity subscale, b = À.03, CI = À.04 to À.01, p < .005, and a marginallysignificant effect on the conduct subscale, b = À.02, CI = À.04 to À.01, p = .01. Lower reading accuracy ability was associatedwith more behavioral difficulties. There was no relationship between reading accuracy and the emotional or peer subscales,p > .3. Similar to the language ability results, the relationship of reading accuracy at age 7 with behavioral, emotional andsocial problems remained constant from age 7 to age 16. The reading ability by age interactions revealed no significantdifferences, ps > .3. 2 The age by pragmatic language interaction term for the hyperactivity subscale was marginally significant, b = .01, CI = .001–.02, p = .03. The remainder of the interaction terms were ps > .07.
  9. 9. [()TD$FIG]194 M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199Fig. 5. SDQ total difficulties score and all subscale scores by age 7 reading accuracy ability for all ages (solid line) and separated into age 7, 8, 11 and 16predictive trajectories.4. Discussion4.1. 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 ofprevious research findings, we expected that overall BESD would decrease from childhood to adolescence. This was notborne 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 developmentaltrajectories observed for specific areas of functioning. Behavioral difficulties in terms of both hyperactivity and conductproblems decreased from childhood to adolescence, as did emotional problems. In contrast, we found evidence of increasingdifficulties in peer relations over the nine year period studied. These patterns of development applied to both males andfemales. SLI has long been associated with BESD (Beitchman, Nair, Clegg, Ferguson, & Patel, 1986; Cantwell et al., 1981; Lindsayet al., 2007). An inspection of the group means throughout development revealed BESD scores were generally in the sub-clinical range, higher than would be expected in the typical population but lower than the mean impairment threshold. Thus,individuals with a history of SLI, in general, are not exhibiting difficulties which alert professionals to the need for referral.This may mean that in practice at least some individuals with a history of SLI are living with difficulties for which they are notreceiving support. This fact needs to be taken into consideration hand in hand with our finding that there were alsoindividual differences in the nature and severity of the problems experienced. This may account for some of theinconsistency of the findings reported in this area. Individual differences can be extreme and are important. They can alsovary across domains of functioning. In this study, variation was evident in the proportion of individuals who scored above theimpairment threshold for each domain and across time. Furthermore, our data reveal differential developmental vulnerability for specific aspects of BESD in SLI. Thus, in SLI,behavioral, emotional and social problems are not associated with equally strong developmental trajectories. Behavioraldifficulties of the hyperactivity and conduct types are more prevalent in childhood but decrease to general population levelsby adolescence. This developmental pattern for behavioral difficulties has also been observed for individuals with readingdifficulties (Maughan et al., 1996). A decrease was also observed for emotional difficulties. However, emotional problemsstill remained above population norms. Difficulties in peer relations were found to be the most developmentally vulnerablearea of functioning in individuals with a history of SLI. This is consistent with previous research documenting socialdifficulties in children and adolescents with SLI (Benasich et al., 1993; Botting & Conti-Ramsden, 2000; Conti-Ramsden &
  10. 10. M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199 195Botting, 2004, 2008; Durkin & Conti-Ramsden, 2007; Lindsay et al., 2007; Redmond & Rice, 1998, 2002; Snowling et al.,2006). An increase in peer problems and in the proportion of individuals functioning in the impaired range was observedfrom childhood to adolescence. By 16 years of age, nearly 40% of individuals with a history of SLI appear impaired in theirinteractions with peers. Thus, SLI appears to be strongly associated with peer difficulties across development.4.2. Language, reading and BESD: examining developmental relationships The early measures of language abilities and reading skills used in this investigation were related in a similar manner toBESD at different age points. In other words, early expressive language and reading abilities were related in a similar mannerto childhood difficulties as they were to adolescent difficulties. This result must be viewed in line with other findings thathave indicated that in SLI, language and reading abilities in relation to peer norms remain remarkably stable acrossdevelopment (Conti-Ramsden et al., under review; St Clair et al., 2010). Thus, the maintenance of the relationship betweenBESD and early language and reading abilities is likely due to the consistency of individuals’ language and reading skills fromage 7 onwards. Early language abilities and reading skills, however, exerted different types and degrees of influence on BESD. Consistent withthe previous literature, early reading accuracy skills were only developmentally predictive of behavior problems (Maughan et al.,1996; Tomblin et al., 2000). Severity of early reading accuracy difficulties was found to be associated with hyperactivity andconduct problems in the present study. Levels of early reading skills were not associated with emotional problems or socialdifficulties in peer relations. Thus, the associations between literacy skills and BESD were specific and circumscribed. In contrast, oral language abilities appeared to be more intricately associated with the development of BESD. However,the pattern was not identical for each of the three aspects of language studied. Pragmatic abilities were associated with BESDgenerally as well as with each specific domain examined (to different degrees). Early expressive language, like reading skills,was associated solely with behavioral difficulties. Early receptive language ability did not appear to relate directly to any ofthe specific BESD domains examined. It needs to be noted, however, that the measure used was the TROG (Bishop, 1982),which is designed to examine understanding of sentential grammar within a multiple choice context. This measure oflanguage comprehension may not be as connected to behavioral, emotional and social functioning as measures which tapmore dynamic and protracted processing of language, such as comprehension of discourse (Bishop, 1997). Increasing difficulties with peer relations observed in the young people with a history of SLI may be at least partly due tothe central role of language in peer interactions during adolescence. Talk with peers increases dramatically from childhoodto adolescence (Raffaeli & Duckett, 1989). What this study makes clear is that pragmatic aspects of language seem to be moredirectly implicated in peer relation problems in individuals with a history of SLI. Other aspects of language did not revealstatistically significant effects. Expressive language difficulties may be more readily observed by others and perhaps for thisreason may be more likely to be accommodated by peers. Problems in understanding language structure may lead todiscomfort in peer communication and possibly breakdowns, but compensatory strategies involving the use of simplergrammatical structures may circumvent some of these difficulties. Pragmatic skills, such as the ability to make inferences inconversation, understand the perspective of others and appreciate humor, however, are more likely to impact on howadolescents ‘‘tune in’’ with peers during social interaction. However, it needs to be noted that the present study used singleinstruments to assess each of the areas of functioning examined. Thus, the results need to be interpreted with some cautionand are in need of further replication in future longitudinal research. To conclude, there appear to be distinct developmental trajectories for behavioral, emotional and social functioning in SLI.An encouraging finding is that behavioral difficulties appear to decrease to normative levels by adolescence. In contrast,those with a history of SLI have poorer long term social, and to a lesser extent, emotional outcomes.Acknowledgements The authors acknowledge the Economic and Social Research Council Fellowship (RES-063-27-0066) awarded to thecorresponding 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 Zoe Simkin for assisting in data collection and organisation. We wouldalso like to thank Alessandra Iervolino, Barbara Maughan, Robert Goodman, and Stephan Collishaw for use of the Rutter B-scale/SDQ calibration samples previously collected as part of a study funded by the Nuffield Foundation.Appendix A. Self-report to teacher-report calibration at age 16 The child’s main teacher in primary school was the informant for this study. In secondary school, the informant was theteacher that was deemed to know the young person best (e.g. form tutor, special needs support teacher, or a specific subjectteacher). There is a possibility that the longitudinal differences observed in the SLI sample studied (decreasing BESDproblems except for the peer subscale) were due to the fact that teachers in secondary school are generally not as wellacquainted with their students as teachers in primary school. Thus, secondary school teachers may under-report problemsdue to insufficient knowledge of their students.
  11. 11. 196 M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199Table A1Average SDQ self-report and teacher report problems in the SLI sample (at age 16) and the adolescent normative sample. SDQ score SLI self-report (SR) SLI teacher (T) SLI SR -T Norms self-report Norms teacher Norms SR-T SLI-Norms Total 13.33 (5.92) 9.62 (6.54) 3.71 10.3 (5.2) 6.3 (6.1) 4.0 p = .97 Hyperactivity 4.46 (2.45) 3.35 (2.81) 1.11 3.8 (2.2) 2.6 (2.7) 1.2 p = .19 Conduct 2.53 (1.74) 0.92 (1.53) 1.61 2.2 (1.7) 0.9 (1.7) 1.3 p = .45 Emotion 3.85 (2.47) 2.45 (2.36) 1.40 2.8 (2.1) 1.3 (1.9) 1.5 p = .15 Peer 2.48 (1.87) 2.92 (2.40) À0.44 1.5 (1.4) 1.4 (1.8) 0.1 p > .01 Examination of the data from the normative sample suggests this is not the case. Data reveals no decrease in the number ofproblems reported by teachers during the primary school years compared to the secondary school years, indicating that thechanging nature of teacher–student relationships does not appear to alter the teachers’ perception of students’ strengths anddifficulties (Meltzer, Gatward, Goodman, & Ford, 2000). We were in the fortunate position to have collected both self-report andteacher-report versions of the SDQ at 16 years. Thus, we were able to directly compare our findings at 16 years for both informants(self and teacher) with those of the normative sample reported by Meltzer et al. (2000). The results are presented in Table A1. Ascan be seen, the differences between the self-report and teacher report forms of the SDQ are not significantly different betweenour SLI sample and the normative sample. There was only one marginal difference for the peer scale and this was not in thedirection of under-reporting by teachers (when compared to self-report).Appendix B. SDQ score calibration from Rutter items At age 7 and 8 the Rutter Behavioural Questionnaire was completed by the teachers of the individuals in the SLI sample. Thisquestionnaire has been used extensively for several decades and consists of a total score as well as antisocial and neuroticsubscales. However, in order to examine developmental trends we required a common scale spanning all periods of follow-up.The Rutter Questionnaire data at ages 7 and 8 were therefore rescored into the subscales and response format of the SDQ used inthe assessments at ages 11 and 16. This was done by exploiting the detailed item-level pattern of association that could beestimated from a cross-instrument calibration sample (Collishaw, Maughan, Goodman, & Pickles, 2004) kindly made available tous, that is a sample of 313 children aged between 6 and 9 for whom both Rutter and SDQ measures had been completed. All of theRutter items that were in both the SLI sample and the calibration sample were used to predict the SDQ subscales, these beingsummed to give a total score. The gender of the SLI and calibration participants was also accounted for in the imputation equation.A full list of the exact Rutter questions used in the imputation is included in Table B1. In order to recognise the uncertainty in such a rescoring, we used the method of multiple imputation. This involved generating20 datasets in which the scores at age 7 and 8 could differ across the datasets, the extent of variation reflecting how well or poorlythe calibration sample suggested that an SDQ score could be predicted from a set of responses from a Rutter questionnaire. Theresults from the analysis of these 20 datasets were then combined using Rubin’s formula to calculate appropriate average means,trends and coefficients with appropriate confidence intervals and p-values. The multiple imputation was undertaken in Stata/SE(StataCorp, 2007) using the iterative chained equation method implemented in the ice procedure and the combining of resultsacross datasets used the micombine procedure (Royston, 2005). Table B1 Age 7 and 8 Rutter Items used for calibration. Very restless. Has difficulty staying seated. Truants from school. Squirmy, fidgety child. Often destroys own or others’ belongings. Frequently fights or is quarrelsome with other children. Not much liked by other children. Often worried or worries about many things. Tends to do things on own—rather solitary. Irritable—quick to ‘‘fly off the handle’’. Often appears miserable, unhappy, tearful or distressed. Is often disobedient. Cannot settle to anything for more than a few moments. Tends to be fearful or afraid of new things or new situations. Fussy or over-particular child. Often tells lies. Has stolen things on one or more occasion in the last 12 months. Has had tears on arrival to school or has refused to enter the building in the last 12 months. Has a stutter or stammer. Bullies other children.
  12. 12. M.C. St Clair et al. / Journal of Communication Disorders 44 (2011) 186–199 197Appendix C. Additional information on the statistical analyses Because SDQ subscale scores are highly skewed, for formal inference they were analyzed as ordinal variables. To accountfor the within-subjects correlation over time in these repeated measures, trends were estimated by maximum likelihoodusing a random intercept ordinal logistic regression model fitted using adaptive quadrature in the procedure gllamm(Generalised Linear Latent and Mixed Models – The gender of the SLI participants was used as a covariatein all analyses. The method accounts for bias due to attrition on an assumption that losses may be selective of individualswith higher or lower observed measures but does not allow additional selective loss associated with the unobservedmeasures (Missing at Random). The SDQ total difficulties score had variable range between the 20 sets of imputed data, which made the analysis impossible.Therefore, the top of the SDQ range was grouped to one value after the score of 25 (which was the lowest score that was missing inone of the 20 sets of data). This equated all imputations and allowed the analysis to run correctly. All scores above 25 were recodedas 25. This grouping affected only the top 4% of SDQ total difficulties scores. Logistic regressions were conducted across time on the proportion of impaired individuals for the SDQ total difficulties scoreand the four subscales. A categorical age measure was used to determine whether the impairment distribution differed betweenthe time points. The graphs of trends in cohort mean scores were compiled from fitted values from a multilevel mixed-effects linear regressionmodel (xtmixed with a random intercept; Fig. 1). The mixed effects regression model had a categorical age (7, 8, 11 and 16) andgender fixed effects. Fitted data were preferred to raw data as this accounted for attrition over time. The normative line included inFig. 1 was adjusted for the specific gender distribution in the current sample (normative means for the males and female wereweighted and averaged based on the gender distribution in the SLI sample). Each of the curves in Figs. 2–5 are prediction plotsbased on the raw data, which indicate the predictive curve of the relationship between language/literacy and SDQ scores given theraw data.Appendix D. Continuing education questions1. Individuals with a history of SLI showed increasing problems throughout development in which area of difficulty? a. Hyperactivity difficulties b. Conduct difficulties c. Emotional difficulties d. Social (peer) difficulties2. Individuals with a history of SLI have severe and persisting behavioral problems from childhood to adolescence. True/False3. Adolescents with a history of SLI showed sustained difficulties in which two areas? a. Social (peer) and emotional difficulties b. Emotional and hyperactivity difficulties c. Hyperactivity and conduct difficulties d. Social (peer) and conduct difficulties4. What aspect of language/literacy ability was related to all measures of BESD in individuals with a history of SLI? a. Expressive language b. Reading accuracy c. Pragmatic language d. Receptive language5. What statement best describes the relationship between reading accuracy in childhood and BESD in individuals with a history of SLI? a. High reading accuracy ability was related to increased rates of behavioral and emotional problems. b. High reading accuracy ability was related to lower rates of behavioral problems throughout development. c. High reading accuracy ability was related to fewer behavioral, emotional and social difficulties throughout development. d. High reading accuracy ability was related to fewer behavioral problems in childhood, but was not related to problems in adolescence.ReferencesBaker, L., & Cantwell, D. P. (1982). Language acquisiton, cognitive development, and emotional disorder in childhood. In Nelson, K. E. (Ed.). Children’s language (Vol. 3). Hillsdale, NJ: Lawrence Erlbaum Associates.Beitchman, J. H., Brownlie, E. B., & Wilson, B. (1996). Linguistic impairment and psychiatric disorder: Pathways to outcome. In J. H. Beitchman, N. J. Cohen, M. M. Konstantareas, & R. Tannock (Eds.), Language, learning and behavior disorders: Developmental, biological, and clinical perspectives. Cambridge: Cambridge University Press.
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  15. 15. Revista de Trastornos de la Comunicación Un estudio longitudinal de problemas de conducta, emocionales y sociales en los individuos con antecedentes de trastorno específico del lenguaje (SLI) Michelle C. St Clair a, Andrew Pickles b, Kevin Durkin c, Gina Conti-Ramsden a,*AbstractLos niños con trastorno específico del lenguaje (SLI) a menudo han sido informado que se lesasocia a problemas de conducta, emocionales y sociales. La mayoría de estudios anterioresimplican observaciones en un sólo punto de tiempo, o diseños seccionales cruzados, y la evidencialongitudinal de las trayectorias de desarrollo de las dificultades particulares es limitada. ElCuestionario de Capacidades y Dificultades se utilizó para medir problemas de comportamiento(hiperactividad y conducta), emocionales y sociales (entre pares) en una muestra de individuoscon un historial de SLI en cuatro momentos de la infancia (7 años) hasta la adolescencia (16 años).Una disminución en los problemas emocionales y de comportamiento se observó desde la infanciahasta la adolescencia, a pesar de que los problemas emocionales eran aún evidentes en laadolescencia. Por el contrario, hubo un aumento en los problemas sociales. Las habilidades delectura y el lenguaje expresivo se relacionaban únicamente a los problemas de conducta. Lashabilidades pragmáticas se relacionaron con problemas de conducta, emocionales y sociales.Como grupo, los que tienen un historial de SLI tienen peores resultados a largo plazo, emocionalesy sociales, en menor medida. En contraste, los problemas de conducta parecen disminuir a nivelesnormativos en la adolescencia. Diferentes aspectos de las habilidades del lenguaje precoz y lashabilidades de lectura ejercen distintos tipos y grados de influencia en las dificultades decomportamiento, emocionales y sociales. Los resultados del aprendizaje: los lectores seráncapaces de: (1) comprender los tipos de problemas de conducta, emocionales y sociales presentesen los individuos con una historia de SLI, (2) estar familiarizado con la trayectoria de desarrollo deestas dificultades desde la infancia hasta la adolescencia, y (3) comprender las relaciones entre losproblemas de conducta, emocionales y sociales y el lenguaje y la capacidad de la alfabetizacióntemprana.1. IntroductionEl trastorno específico del lenguaje (SLI)1 es un trastorno de desarrollo que implica alteracionessignificativas del lenguaje en el contexto de la capacidad normal no verbal, el oído, y el estadoneurológico (Bishop, 1997; Leonard, 1998). La prevalencia de SLI en los niños pequeños se ha Traducciones: © D.U.I.
  16. 16. estimado en un 7% (Tomblin et al., 1997). Se cree que el 40% de los niños identificados contrastornos del lenguaje tienen continuas dificultades del lenguaje (Ley de Boyle, Harris, Harkness, yNye, 2000), y algunos individuos continuarán teniendo dificultades con el idioma en la edad adulta(Clegg, Hollis, Mawhood, y Rutter , 2005; Howlin, Mawhood, y Rutter, 2000). Cabe señalar, sinembargo, que las personas con SLI demuestran una heterogeneidad considerable en los perfiles defortalezas y debilidades (Conti-Ramsden, 2008). Por lo tanto, la investigación en esta área incluyeencuestas de participantes que no cumplen con la definición tradicional, verbal y no verbal dediscrepancia de SLI. El estudio longitudinal no es una excepción. Sin embargo, seguimos utilizandoel término en SLI para situar nuestros resultados dentro de la literatura de investigación en estaárea con el reconocimiento de que estas personas pueden o no cumplir con los criteriostradicionales SLI de forma continua durante todo el desarrollo. Por esta razón, nos referimos a losparticipantes en este estudio como una historia de SLI.El término Dificultades a corto plazo de Comportamiento, Emocionales y Sociales (BESD) escomplejo y se agrupan en una serie de construcciones relacionadas con aspectos de desarrollo delos jóvenes. Cada uno de estos dominios de funcionamiento es distinto. Sin embargo, el términoBESD puede ser una abreviación útil para proporcionar una cobertura equilibrada de una ampliagama de áreas de funcionamiento en los jóvenes, es decir, comportamientos, emociones yrelaciones. Es ampliamente reconocido que los niños que tienen deterioro específico del lenguajeexperimentan no sólo dificultades con el lenguaje, sino también BESD. La co-ocurrencia(reiteración) del trastorno del lenguaje y BESD se ha encontrado en niños con dificultades de lalengua materna (Beitchman, Hood, Rochon, y Peterson, 1989; Cantwell, Baker, y Mattison, 1981;Lindsay, Dockrell, y Strand, 2007) y también en los niños con problemas psiquiátricos básicos(Cohen et al, 1998;. Gualtieri, Koriath, Bourgondien Van, y Saleeby, 1983). Es aún menos sabido,sin embargo, acerca de las trayectorias de desarrollo de estas dificultades. Este estudio examina eldesarrollo longitudinal de BESD en los niños con un historial de SLI en un período de tiempo denueve años e investiga cómo las habilidades de lenguaje y lectura se relacionan con el curso deldesarrollo de otras dificultades.1.1. SLI y BESD.Los primeros trabajos en este campo se centraron en la prevalencia de trastornos psiquiátricos enlos niños con SLI, particularmente dificultades de comportamiento (Baker y Cantwell, 1982;.Beitchman et al, 1989). Las conclusiones generales indican que las dificultades de comportamientodel déficit de atención e hiperactividad tipo de trastorno (TDAH) pueden co-ocurrir con lasdificultades del idioma. Esto ha sido apoyado por más recientes hallazgos de las dificultadesgenerales de atención en los individuos con SLI (Lum, Conti-Ramsden, y Lindell, 2007), así comouna mayor prevalencia de problemas de comportamiento de hiperactividad y/ó atención entre losniños con TEL, en comparación con los niños con desarrollo del lenguaje típico (Benasich, Curtiss, yTallal, 1993; Snowling, Bishop, Stothard, Chipchase, y Kaplan, 2006). Traducciones: © D.U.I.
  17. 17. En cuanto a las dificultades de comportamiento del tipo de conducta, estudios recientes hanproporcionado evidencia mixta. Algunas investigaciones sugieren más altos niveles deexternalización de las dificultades en la infancia en individuos con SLI (Tomblin, Zhang, Buckwaltery Catts, 2000; van Daal, Verhoeven, y van Balkom, 2004), mientras que otros no (Lindsay et al,2007;. Redmond & Rice, 1998, 2002). En el caso de problemas emocionales, la investigación esescasa y los resultados disponibles tampoco son consistentes. Algunos estudios han encontradoniveles más altos de internalización de las dificultades en la infancia (Coster, Goorhuis-Brouwer,Nakken, y Lutje Spelberg, 1999; Redmond & Rice, 1998, 2002), así como en la adolescencia, enparticular la ansiedad y la depresión (Conti-Ramsden y botting, 2008). Sin embargo, varios estudioshan encontrado poca evidencia de determinados problemas emocionales en los niños con SLI(Snowling et al, 2006;.. Tomblin et al, 2000) o han encontrado evidencia de que el uso demetodologías específicas, por ejemplo el informe del profesor, pero no informe de los padres(Redmond & Rice, 1998, 2002). Un gran cuerpo de literatura apunta a la presencia de dificultadessociales de los niños y adolescentes con SLI (Benasich et al, 1993;. Conti-Ramsden y Botting, 2004;.Lindsay et al, 2007). La investigación sugiere dificultades con el aislamiento social. Los niños conSLI tienen más probabilidades de jugar solos y muestran síntomas de timidez (Fujiki, Brinton,Isaacson, y Summers, 2001). Algunos estudios han reportado la timidez sólo para las niñas con SLI(Benasich et al, 1993;. Tallal, Dukette, y Curtiss, 1989).Hay pruebas más consistentes, sin embargo, sobre dificultades de relaciones entre pares (Fujiki,Brinton, Morgan & Hart, 1999; Gertner, Arroz y Hadley, 1994), calidad más pobre de amistades(Durkin y Conti-Ramsden, 2007) y riesgo de victimización (Knox y Conti-Ramsden, 2007). En suma,las tendencias en la literatura sugieren que el TDAH es probable que co-ocurran en individuos conSLI, al menos en la niñez. La evidencia respecto a la conducta y las dificultades emocionales esmenos consistente. Con respecto a las relaciones con los compañeros, los niños y adolescentescon SLI parecen estar en desventaja. Sin embargo, a pesar de una creciente literatura enriquecenuestro conocimiento de BESD en SLI, diferentes estudios han examinado los diferentes grupos deedad y han incluido diversas medidas, haciendo difíciles las comparaciones entre conjuntos dedatos. Preguntas sobre el curso del desarrollo todavía no se han abordado.La investigación longitudinal ha sido limitada, tanto en términos de alcance y amplitud de lasmedidas de BESD utilizados. Redmond y Rice (2002) encontraron una disminución en losproblemas emocionales en los niños con SLI de 5 a 7 años de edad, pero también observó lospatrones más estables de los problemas de atención y social a través de este período de tiempo.Benasich y sus colegas (1993) informaron que no hubo cambio en el desarrollo de 4 a 8 años deedad en una medida global de los problemas de conducta en los niños con SLI. Examinando niñosmayores con SLI de 7 a 11 años de edad, Silva, Williams y McGee (1987) encontraron unadisminución en una medida global de BESD, al igual que Lindsay y sus colegas (2007) de 8 a 12años de edad con SLI. Estos datos sugieren que puede haber una disminución en BESD en los niñoscon TEL desde principios de la infancia. En este sentido, los individuos con SLI pueden ser similaresa las personas con discapacidad de lectura. Maughan y sus colegas (1996) encontrarondisminución de atención y problemas de conducta desde la niñez hasta la adolescencia en su Traducciones: © D.U.I.
  18. 18. muestra de la lectura de jóvenes discapacitados. Los datos anteriores también plantean laposibilidad de que los aspectos específicos de funcionamiento conductual, emocional y socialpueden diferir en sus trayectorias de desarrollo.1.2. BESD y su relación con los trastornos de lectura y lenguaje.En la literatura existente, el informe sobre la asociación entre el lenguaje y alteraciones BESD esun poco limitado y se mezcla, dependiendo del área de funcionamiento que se examina y los tiposde medidas que se utilizan. Benasich et al. (1993) y Hart, Fujiki, Brinton, y Hart (2004) no encontróninguna relación discernible entre las habilidades del lenguaje y los resultados conductuales en lainfancia. Sin embargo, Botting y Conti-Ramsden (2000) encontraron mayor número de niños conSLI por encima del umbral clínico de problemas de conducta/social a las edades de 7 y 8 cuandotenían problemas con el idioma que involucran más de una modalidad lingüística. Snowling et al.(2006) también informó de que un perfil con dificultades lingüísticas expresivas y receptivascombinadas estaban relacionadas con problemas sociales. Las dificultades que implican el dominioexpresivo sólo se asocia con problemas de atención/hiperactividad. Del mismo modo, Durkin yConti-Ramsden (2007) encontraron que el lenguaje receptivo a la edad de 7 años difería enresultados sociales en términos de buenas amistades en comparación con pobres amistades a los16 años. En general, las habilidades lingüísticas también han sido asociados con problemas deconducta (Lindsay et al., 2007), incluida la atención/hiperactividad (Redmond y Rice, 2002). Estosestudios abren la posibilidad de que distintos aspectos del lenguaje puedan estar relacionados condiferentes áreas de funcionamiento en los dominios conductuales, emocionales y sociales(Beitchman, Brownlie, y Wilson, 1996).Lindsay et al. (2007) proporciona una importante evidencia adicional de que las medidas de lashabilidades pragmáticas están relacionados con problemas de conducta, aunque el uso de unamedida global de BESD en este estudio significa que la relación con áreas específicas defuncionamiento sigue siendo investigado. Problemas con la lectura también se han relacionadocon BESD (Maughan et al., 1996). En particular, las dificultades en cuanto a lectura se refieren sehan asociado con problemas de conducta en la infancia, tanto en la atención/hiperactividad y enlos dominios de la conducta (Frick et al, 1991;.. Maughan et al, 1996). Curiosamente, los individuoscon SLI a menudo presentan deficiencias en la lectura (Bishop y Adams, 1990; Botting, Simkin, yConti Ramsden, 2006; Snowling, el obispo, y Stothard, 2000). Sin embargo, la investigación queexamina la asociación entre las deficiencias de lectura y BESD en individuos con SLI es algo muyreciente. La evidencia hasta ahora sugiere que las dificultades de lectura en SLI están relacionadascon problemas de conducta, especialmente de los tipos de atención/hiperactividad y conducta,pero no a las dificultades emocionales (Tomblin et al., 2000). Traducciones: © D.U.I.
  19. 19. 1.3. Estudios recientes.Aunque hay varios estudios que apuntan a la presencia de BESD en individuos con SLI, muchomenos se sabe respecto de las trayectorias de desarrollo de sus dificultades. Hasta dondesabemos, este estudio es el primero en investigar BESD en individuos con SLI desde la niñez hastala adolescencia y su relación con el lenguaje y las habilidades de lectura. Se incluyó una medidaglobal de BESD e investigó cuatro dominios específicos de funcionamiento: dos dominiosrelacionados con problemas de conducta, es decir, la hiperactividad y la conducta, así comoproblemas emocionales y dificultades en las relaciones entre iguales. Basado en la literaturaanterior, esperábamos encontrar una disminución de la BESD en general a través del tiempo. Encuanto a las áreas específicas de funcionamiento, una base para predicciones es menos clara. Seanticipó que era probable descubrir las diferencias en las trayectorias de desarrollo de áreasespecíficas de funcionamiento, con la literatura que sugiere relaciones entre pares comoespecialmente problemático para las personas con SLI. También tuvo como objetivo investigar lasrelaciones de desarrollo entre las habilidades del lenguaje y BESD y entre las habilidades de lecturay BESD. Se examinaron tres aspectos de la lengua—expresivas, receptivas y pragmáticas, así comola precisión de lectura.2. Método.2.1. Participantes.Los participantes fueron personas con un historial de SLI que fueron parte del Estudio de IdiomaManchester (Conti-Ramsden y Botting, 1999a, 1999b; Conti Ramsden, Crutchley, y Botting, 1997).La cohorte original de 242 niños representó una muestra aleatoria del 50% de todos los niños quecursaban 2° grado (7 años) en las dependencias de idiomas en Inglaterra. Las unidades lingüísticasse suelen colocar en los centros ordinarios. Son aulas especializadas creadas para apoyar a niñoscon dificultades de lenguaje básico. Los niños reportados por los maestros a tener dificultadesneurológicas francas, los diagnósticos de autismo, deficiencias auditivas o conocidos problemasauditivos o deficiencias generales de aprendizaje se han excluido. Todos los niños tienen Ingléscomo primera lengua, pero el 12% habían estado expuesto a otros idiomas aparte del Inglés en elhogar. El consentimiento informado se obtuvo de todos los participantes. Este estudio incluye 234niños de la cohorte de estudio inicial de 6-5 años, 7-9 años (mujeres: 23,5%) con reevaluaciones alos 8 años (n = 203), 11 (n = 167) y 16 (n = 103). El desgaste observado se debió en parte a lasrestricciones de financiación en las fases de seguimiento del estudio. Tampoco hubo diferenciatanto en aquellos de 7 años, en términos habilidades lingüísticas receptivas como expresivas, losque participaron a los 16 y aquellos que no participaron, ps> 0.8.Sin embargo, dado que el número de participantes varió en los diferentes puntos de tiempoevaluados, era necesario tener esto en cuenta en nuestros análisis longitudinales. Por lo tanto, seemplearon los modelos estadísticos que dan cuenta de desgaste de los participantes. El métodoutilizado informa sobre el sesgo debido a la deserción en el supuesto de que las pérdidas pueden Traducciones: © D.U.I.
  20. 20. ser selectivas de las personas con mayores o menores medidas observadas, pero no permite unapérdida adicional selectiva asociada a las medidas no observadas (Pérdidas al Azar). El resumen delas habilidades del lenguaje en estos niños a la edad de 7, 8, 11 y 16 se muestra en la Tabla 1. Elresultado del coeficiente intelectual (CIM) a la edad de 7 años (Matrices Coloridas Progresivas deRaven;, 1986) estaba dentro del rango normal, M = 105.98, SD = 14,89. No encontramos que elCIM estuviera relacionado con el total de puntuación de las dificultades SDQ, ni ninguna de lassubescalas, ps 0.1>. Además, los ingresos de los padres y la educación de la madre a los 16 añosfueron analizados en relación a las dificultades SDQ totales y las cuatro subescalas. No hubodiferencias entre los cuatro niveles de ingresos de los padres (<£ 10.401, £ 10.401 - £ 20.800, £20.801 - £ 36.400, y> 36.401 libras, en los niveles de ingresos entre 2003-2005) ni para lapuntuación total del SDQ las dificultades ni por cualquier una de las subescalas, ps> .05. Tampocohubo diferencias entre los tres niveles de educación de la madre (sin cualificación, formacióneducativa básica [GCSE/O a nivel de cierta formación educacional] y educación superior[grado/posgrado de universidad]) para la puntuación total del SDQ o para cualquiera de lossubescalas, p> 0.3.A pesar de que todos los niños asistieron a las unidades lingüísticas a los 7 años, el 15,5% (31) setrasladaron a los centros ordinarios sin apoyo a los 8 años y un 13,5% (27) más se trasladaron a loscentros ordinarios con el apoyo a los 8 años. Sin embargo, el 64,0% (128) o bien se quedó en lamisma unidad de lengua o se cambiaron a otra unidad de lenguaje similar. Una minoría de losniños (6,5% o niños de 13 años) se inscribieron en unidades especiales o en escuelas. No huboinformación disponible para tres de los niños. A los 11 años, el 13% (21) de la muestra fue en laeducación general sin apoyo con un 51% más (82) con el apoyo. Sólo el 11,1% (18) se mantuvo enlas dependencias de idiomas, mientras que el 4,3% (7) se colocó en las escuelas de idiomas. Unadicional de 18,5% (30) fue colocado en escuelas especiales y el 2,5% (4) fue retenido en la escuelaprimaria. No hubo información disponible para los restantes 5 a los 11 años. A los 16 años, el16,5% (17) se encontraban en los centros ordinarios sin apoyo, mientras que el 51,5% (53) estabanen la unidad principal con apoyo. Las unidades lingüísticas fueron asistidas en un 1,9% (2) yescuelas de idiomas en un 3,9% (4). Además, el 4,9% (5) asistió a una unidad especial, mientrasque el 21,4% (22) asistió a una escuela especial.2.2. Medidas.La versión del informe del profesor sobre El Cuestionario de Capacidades y Dificultades (SDQ) seutilizó para medir BESD (Goodman, 1997). Dada la naturaleza cambiante de las relaciones de losdocentes con los estudiantes de escuela primaria a la secundaria, la posibilidad desubnotificaciones por los profesores de enseñanza secundaria fue investigada. Nuestros resultadosindican que éste no era el caso y, además, no había comparación entre el profesor y el informe deauto-reporte del SDQ (ver Apéndice A). El SDQ incluye una puntuación total de dificultades, asícomo cuatro subescalas de medición sobre dificultades conductuales (hiperactividad y conducta),emocionales y sociales (relaciones con los compañeros). Las puntuaciones de SDQ a las edades de Traducciones: © D.U.I.
  21. 21. 7 y 8 fueron calibrados utilizando la imputación múltiple del Cuestionario de Comportamiento deRutter (Rutter, 1967). Todos los detalles de este procedimiento se pueden encontrar en elApéndice B. El SDQ tiene un punto de corte de 12 en la puntuación total de dificultades, ya queéste era el mejor indicador clínico de problemas psiquiátricos (Goodman, 1999). Los puntos decorte clínicos para las subescalas de la versión del maestro (6, 3, 5 y 4 o por encima de lahiperactividad, conducta, emocionales y las subescalas de pares, respectivamente) indican que el80% de los niños de una muestra comunitaria se considera normal, dejando 20 % sobre el puntajede corte. Estos oscilaron entre el límite y anormal (Goodman, 1997). En el presente estudio,combinamos aquellos que calificaron en el rango límite superior del normal, como deteriorada”.Las medidas del lenguaje a la edad de 7 y 11 fueron utilizadas. A los 7 años, el lenguaje expresivose midió con La Historia del Bus (Renfrew, 1991). La prueba de la recepción de la gramática (TROG;Bishop, 1982) se utilizó para medir el lenguaje receptivo a los 7 años. A los 11 años, los maestroscompletaron la escala pragmática de la Lista de verificación de Comunicación de los Niños (CCC;Bishop, 1998). Las puntuaciones altas (132 o más) en esta escala indican que no hay problemaspragmáticos; puntuaciones por debajo de 132 indican deterioro pragmático. Las medidas delectura a los 7 años también fueron utilizados en los análisis. Los participantes completaron lalectura de una palabra de la Escala de Habilidades Británico (BAS, Elliot, 1983), una medida delectura de una sola palabra. Los puntajes de palabras sin procesar de La Historia del Bus, TROG yBAS fueron trasladados a un rango percentil basado en las normas publicadas de la población yluego convertidas en puntuaciones estándar (con una media de 100 y desviación estándar de 15)para fines de comparación.2.3. Análisis estadístico.El programa estadístico Stata/SE (StataCorp, 2007) se utilizó para todos los análisis estadísticos. Elgénero de los participantes fue una covariable en todos los análisis. Debido a que las puntuacionesSDQ de la subescala están muy sesgados, por inferencia formal se analizaron como variablesordinales utilizando el Latente Lineal Generalizado, y el Procedimiento de Modelos Mixtos— (Rabe-Hesketh, Skrondal, y Pickles, 2002). Los gráficos de tendencias en laspuntuaciones medias de cohortes fueron compilados de valores ajustados desde un modelo deregresión lineal y efectos de multiniveles mixtos. En todos los análisis, la falta de independencia yel desgaste de los datos longitudinales se tuvieron en cuenta en virtud de una supuesta falta deforma aleatoria. Los resultados de los conjuntos de datos imputados se combinaron usando laregla de Rubin. Para el control de comparaciones múltiples, el nivel de significación se fijó a unnivel de .01. Sin embargo, por interés, mostramos los resultados como marginal cuando alfa varióentre 0,01 y 0,05 para las principales conclusiones. Todos los detalles de estos análisis sepresentan en el Apéndice C. Traducciones: © D.U.I.
  22. 22. 3. Resultados.3.1. Trayectorias de desarrollo de BESD en SLI.El puntaje total de dificultades, así como todas las subescalas se analizaron longitudinalmente paradeterminar si el BESD aumentó o disminuyó en los individuos con SLI de la niñez a la adolescencia.Todos los análisis se llevaron a cabo en términos de tendencias lineales y cuadráticas, y si lastendencias son significativas o marginalmente significativas, también categóricamente (laspruebas directamente en los períodos de diferentes edades). La importancia marginal en lastendencias generales se reportan, pero para los análisis categóricos sólo se reportan diferenciassignificativas para facilitar la lectura con una sola excepción, ya que su inclusión aclara losresultados. Como no hubo tendencias de segundo grado en los datos, sólo los modelos lineales ycategóricos se discuten. Una edad por términos de interacción de género también se incluyó entodos los análisis longitudinales, pero la interacción no resultó ser significativa, lo que indica quelas tendencias longitudinales fueron consistentes para los individuos masculinos y femeninos conSLI. Ver fig. 1 para la representación gráfica de las trayectorias de desarrollo y en la Tabla 2 paramedias y desviaciones estándar.La tendencia lineal para la puntuación total de las dificultades SDQ no fue significativa, b = 0.05, CI= .10 a .001, p = .06. Sin embargo, hubo diferencias significativas en varias de las subescalas delSDQ. Hubo una tendencia lineal significativa en la subescala de hiperactividad, b = 0.08, CI = .13 a.03, p <.005, lo que indica un menor número de dificultades que la hiperactividad en el tiempo.Hubo significativamente menos problemas de hiperactividad a los 16 años que a los 7 y 8 años, b =0,67, IC = 1,14 hasta 0,19, p <0,01 y b = 0,71, IC = 1,24 a 0.18, p <.01, respectivamente. Unatendencia lineal significativa en la subescala de conducta, b = 0.14, CI = .20 a .07, p <.001, indica unmenor número de problemas a través del tiempo. Cuando se probó categóricamente,significativamente se produjo menos problemas de conducta a los 16 años que en las edades de 7y 8, b = 1,13, IC = 1,71 a 0,56, p <0.001 y b = 1,09, IC = 1,77 a 0,42, p <.005 . Además, lasdificultades reportadas a los 11 años eran menos que los reportados a la edad de 7, b = 0,66, IC =1,15 hasta 0,16, p <.01. Hubo una tendencia lineal marginalmente significativa en la subescalaemocional, b = 0.06, CI = .11 a .01, p = .01, en el que, en general hubo menos problemasemocionales con el tiempo. Cuando se probó categóricamente, se encontró que a los 16 años de lamuestra SLI tuvieron significativamente menos problemas emocionales que a los 8 años, b = 0,77,IC = 1,29 hasta 0,25, p <.005. Por el contrario, una tendencia lineal significativa en a subescala depares, b = 0.09, CI = .02 a .15, p <.01, indicaron un aumento en problemas con sus pares a travésdel tiempo. Las diferencias categóricas no mostraron efectos significativos entre las edades de 7,8, 11 y 16, ps> .01 (hubo incrementos marginales en problemas con sus pares de la edad de 7 añosa las edades de 11 y 16, b = 0,64, IC = 0,11 a 1,16, p = 0,02 yb = 0,72, IC = 0,17 hasta 1,27, p = .01),lo que indica que el aumento de problemas con sus pares en el lapso de tiempo de nueve años fuegradual.Es importante tener en cuenta las puntuaciones medias porque todas las puntuaciones SDQcayeron por debajo de lo que se considera un nivel de dificultad clínico. La Tabla 2 presenta la Traducciones: © D.U.I.