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Running title: Communication disorders 3
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Explain how understanding the conceptual model of working
memory helps you in selecting strategies to take in helping a
child that may have a communicative disorder. Please give an
example of a strategy that you might use with a child with a
specific communicative disorder.
Construct a scenario of a team approach that could be
developed when working with a child that has a specific
communicative disorder. You should identify the
communicative disorder that the child has in this scenario and
provide research and techniques/strategies that are known to be
effective with this type of communicative disorder.
Evaluate the benefits for family and children in being
connected to organizations associated with a specific
communicative disorder. These organizations can be found from
the list in your chapter reading or from an internet search.
Explain how understanding the conceptual model of working
memory helps you in selecting strategies to take in helping a
child that may have a communicative disorder. Please give an
example of a strategy that you might use with a child with a
specific communicative disorder.
Understanding the communication disorder is quite convenient
towards the selection of the best mode of commiunication with a
disabled child. (Sigman & Norman,1999). When am able to
know some causes of communication disorders that the child is
facing and this includes hearing loss in a child, neurological
disorders, brain injury, mental retardation, drug abuse, physical
impairments such as cleft lip or palate, emotional or psychiatric
autism, and developmental disorders (Howlin, Mawhood, &
Rutter, 2000), I will be able to freely interact with the child
with the disorder without making him feel bad. This might
include the use of include joint attention, imitation, and toy
play to socialize with the autistic disorder. (Adamson &
Bakeman,1985,1991)
At 14 years, 8 months of age, Sam spontaneously imparted his
aims, through nonverbal means, which included outward
appearances (e.g., looking to staff to demand a nibble), physical
motions (e.g., pulling his educators' hands to his head to
demand a head rub), and more ordinary signals (e.g., indicating
solicitation and a head shake to reject). He likewise utilized
offbeat nonverbal flags that included gnawing his hand to
impart positive and negative feelings and squeezing to dissent.
Sam every so often utilized a couple of verbal word rough
guesses (e.g., "no," "yes," "more," and "inflatable"), the sign for
"help," and picture images on a voice yield gadget. Be that as it
may, he commonly utilized these images latently, regularly
because of a direct verbal brief from his social accomplice.
From research, this shows that this is Autistic Disorder due to
the fact that, he uses a variety of communication modes
including speech, facial expressions, conventional gestures
(e.g., pointing), unconventional signals (e.g., hand-flapping),
vocalizations, picture symbols, and assistive technology (e.g.,
speech-generating devices) McCune, 1995; Ungerer & Sigman,
1984).
There are several advantages that have been analysed in this
article, just to state some, the connection of the family and
disabled children or rather autistic persons is quite important
due to the fact that they are able to connect and understand each
other in their communication and thus makes it easy for the
disabled one to fall in place and they are able to assist the child
Kasari et al. (2004)
References:
Adamson, L., & Bakeman, R. (1985). Affect and attention:
Infants observed with mothers and peers. Child Development,
56, 582–593.
Adamson, L., & Bakeman, R. (1991). The development of
shared attention during infancy. In R. Vasta (Ed.), Annals of
child development (Vol. 8, pp. 1–41). London: Jessica Kingsley
Publishers, Ltd
Clift, S., Stagnitti, K., & Demello, L. (1988). A validation study
of the test of pretend play using correlations and classifica-
tional analyses. Child Language Teaching and Therapy, 14,199–
209.
Dawson, G. (1991). A psychobiological perspective on the early
socioemotional development of children with autism. In S. Toth,
& D. Cicchetti (Eds.), Rochester symposium on developmental
psychopathology
(Vol. 3, pp. 207–234). Erlbaum: Mahwah, NJ
O R I G I N A L P A P E R
Early Predictors of Communication Development in Young
Children with Autism Spectrum Disorder: Joint Attention,
Imitation, and Toy Play
Karen Toth Æ Jeffrey Munson Æ Andrew N. Meltzoff Æ
Geraldine Dawson
Published online: 15 July 2006
� Springer Science+Business Media, Inc. 2006
Abstract This study investigated the unique contribu-
tions of joint attention, imitation, and toy play to language
ability and rate of development of communication skills in
young children with autism spectrum disorder (ASD).
Sixty preschool-aged children with ASD were assessed
using measures of joint attention, imitation, toy play, lan-
guage, and communication ability. Two skills, initiating
protodeclarative joint attention and immediate imitation,
were most strongly associated with language ability at age
3–4 years, whereas toy play and deferred imitation were
the best predictors of rate of communication development
from age 4 to 6.5 years. The implications of these results
for understanding the nature and course of language
development in autism and for the development of targeted
early interventions are discussed.
Keywords Autism Æ Language Æ Communication Æ Joint
attention Æ Imitation Æ Play
Introduction
It is well established that there is tremendous variability in
outcome in autism. Long-term outcome studies have shown
that while a majority of individuals exhibit poor to very
poor outcomes, many individuals with autism go on to
achieve adequate levels of academic, social, and occupa-
tional functioning (Gillberg & Steffenburg, 1987; Lotter,
1978; Nordin & Gillberg, 1998; Sigman & Norman, 1999).
In a recent study that followed children with autism from
age 2 to 9, as many as 40% were found to have good
outcomes based on language and cognitive scores (Stone,
Turner, Pozdol, & Smoski, 2003). One of the strongest
predictors of positive long-term outcomes for children with
autism is the acquisition of spoken language (Bartak, Rutter,
& Cox, 1975; Gillberg, 1991; Gillberg & Steffenburg, 1987;
Lincoln, Courchesne, Kilman, Elmasian, & Allen, 1988;
Lotter, 1978; Rutter, 1970). Early language ability (i.e.,
meaningful speech by 5–6 years of age) has been associated
with both later academic achievement and social
competence in individuals with autism (Howlin, Mawhood,
& Rutter, 2000; Sigman & Ruskin, 1999; Venter, Lord, &
Schopler, 1992). Given the critical importance of early
language development for later prognosis, a better under-
standing of developmental factors that underlie, facilitate,
and predict language acquisition in autism would shed light
on the nature of this disorder and allow for the refinement
of targeted early interventions.
Early abilities that have been associated with the
development of language and communication skills both in
typically developing children and children with autism
include joint attention, imitation, and toy play. Joint
attention—shared attention between social partners
in relation to objects or events—typically emerges by
9–12 months of age (Adamson & Bakeman, 1985, 1991;
Adamson & Chance, 1998; Brooks & Meltzoff, 2002;
Bruner, 1983; Butterworth & Jarrett, 1991; Carpenter,
Nagell, & Tomasello, 1998), with some aspects emerging
as early as 6 months of age (Morales, Mundy, & Rojas,
1998). By 12 months of age, most typical infants display
all aspects of joint attention, including sharing attention
(e.g., through the use of alternating eye gaze), following
the attention of another (e.g., following eye gaze or a
K. Toth (&) Æ J. Munson Æ A. N. Meltzoff Æ G. Dawson
Department of Psychology, UW Autism Center, CHDD,
University of Washington, 357920, Seattle, WA 98195, USA
e-mail: [email protected]
J Autism Dev Disord (2006) 36:993–1005
DOI 10.1007/s10803-006-0137-7
123
point), and directing the attention of another (Carpenter
et al., 1998). Through joint attention interactions, the infant
begins to link words and sentences with objects and events
(Baldwin, 1995). Importantly, it is within the context of
joint attention episodes that infants also begin to commu-
nicate intention by using sounds and gestures, such as
reaching to request objects, and pointing and vocalizing to
direct attention to objects. Joint attention skills correlate not
only with early language learning, but also with later lan-
guage ability in typically developing children (Carpenter
et al., 1998; Meltzoff & Brooks, 2004; Morales et al.,
1998, 2000; Mundy & Gomes, 1998).
Children with autism, however, show impairments in
joint attention skills as compared to children with delayed
and typical development (Bacon, Fein, Morris, Water-
house, & Allen, 1998; Charman, 1998; Charman et al.,
1998; Dawson, Meltzoff, Osterling, & Rinaldi, 1998;
Dawson et al., 2002a, 2004; Mundy, Sigman, Ungerer, &
Sherman, 1986; Sigman, Kasari, Kwon, & Yirmiya, 1992).
Impairments in protodeclarative joint attention behav-
iors—sharing attention for purely social purposes—appear
to be more severe than impairments in protoimperative
joint attention (e.g., requesting) behaviors in children with
autism (Mundy et al., 1986; Mundy, Sigman, & Kasari,
1990; Sigman, Mundy, Sherman, & Ungerer, 1986). Fur-
ther, in preschool age children with autism, joint attention
is predictive of both current language ability, and future
gains in expressive language skills (Bono, Daley, &
Sigman, 2003; Charman et al., 2003; Dawson et al., 2004;
Landry & Loveland, 1988; Mundy et al., 1990; Mundy,
Sigman, Ungerer, & Sherman, 1987; Rogers & Hepburn,
2003; Sigman & Ruskin, 1999; Toth, Dawson, Munson,
Estes, & Abbott, 2003). In a longitudinal study of social
competence and language skills in children with autism and
Down syndrome, Sigman and Ruskin (1999) found that
protodeclarative joint attention skills were associated with
early language ability for both groups, and predicted both
short-term (i.e., 1 year later) and long-term (i.e., 8–9 years
later) gains in expressive language ability for children with
autism. Initiating protodeclarative joint attention in early
childhood (3–6 years of age) was also correlated with later
peer interactions (10–12 years of age). Further, protoim-
perative joint attention skills correlated with early language
ability and short-term, but not long-term, gains in expres-
sive language for children with autism. In a recent inter-
vention study that targeted joint attention skills, young
children with autism showed greater gains in language
12 months post-treatment compared to controls (Kasari,
Freeman, & Paparella, 2004). It may be that joint attention
ability lays a foundation not only for the development of
language, but also other complex abilities such as pretend
play and theory of mind, as argued by developmental
theorists (Bruner, 1983; Carpenter et al., 1998; Meltzoff,
2005; Meltzoff & Brooks, 2001) as well as in the literature
more specifically focusing on children with autism
(Charman, 1997, 2003; Mundy & Crowson, 1997; Sigman,
1997).
Motor imitation ability has also been associated with the
development of language and social communication skills.
In typically developing infants, the ability to imitate is
present at birth. Neonates are able to imitate simple facial
movements, such as tongue protrusion and mouth opening
(Meltzoff & Moore, 1977, 1997). By 9 months of age,
infants are able to imitate actions on objects, both in
immediate and deferred contexts (Carver, 1995; Meltzoff,
1988a). Infant imitation appears to serve several general
functions, providing the child with shared social experi-
ences, a sense of mutual connectedness, and a means of
communication between social partners (Meltzoff, 2005;
Trevarthen, Kokkinaki, & Fiamenghi, 1999). Through
imitation, infants also learn about others’ actions and
intentions (Meltzoff, 1999; Uzgiris, 1981, 1999). Deferred
imitation serves to index infant recall memory and the
child’s ability to produce actions based on stored mental
representations of social events and action sequences (Klein
& Meltzoff, 1999; Meltzoff, 1988b). It has been theorized
that a failure to engage in early social imitative play may
interfere with the development of joint attention, social
reciprocity, and later theory of mind abilities (Dawson,
1991; Meltzoff, 1999, 2005; Meltzoff & Gopnik, 1993;
Rogers & Pennington, 1991). Imitation not only plays an
important role in early social development, but has also
been shown to predict language ability in typically devel-
oping children (Bates, Benigni, Bretherton, Camaioni, &
Volterra, 1979).
While typically developing children demonstrate the
ability to imitate others from birth, children with autism
demonstrate significant impairments in object imitation,
imitation of facial and body movements, and deferred
imitation of actions on objects (Charman, 1997; Dawson
et al., 1998; Rogers, Bennetto, McEvoy, & Pennington,
1996; Rogers, Hepburn, Stackhouse, & Wehner, 2003;
Sigman & Ungerer, 1984; Stone, Ousley, & Littleford,
1997). In children with autism, imitation skills have been
found to correlate with early language ability (Dawson &
Adams, 1984) and to predict later language ability (Charman
et al., 2000, 2003; Stone et al., 1997; Stone & Yoder,
2001). In a recent study, immediate imitation of actions on
objects at 20 months correlated with receptive language at
42 months in a small sample of children with autism
(Charman et al., 2003). In a similar study, motor imitation
at 24 months predicted expressive language ability at
48 months, even after controlling for initial language level,
in young children with autism (Stone & Yoder, 2001).
Play—both functional and symbolic—is a third skill
domain that has been associated with language and social
994 J Autism Dev Disord (2006) 36:993–1005
123
communication ability. Play provides the child with
opportunities for social interaction and social communi-
cation, as well as a context for constructing representations
of intentional states and knowledge (Bloom, 1993; Lifter &
Bloom, 1989, 1998; Piaget, 1952). In typical development,
functional, or pre-symbolic, play emerges during the first
year, while symbolic play begins to emerge around 1 year
of age and becomes increasingly complex over the second
year of life. Both functional and symbolic play skills have
been shown to correlate with language ability in typical
children (Bates et al., 1979; McCune, 1995; Ungerer &
Sigman, 1984). Symbolic play is correlated with both
receptive and expressive language ability (Clift, Stagnitti,
& Demello, 1988; Doswell, Lewis, Boucher, & Sylva,
1994; Lewis, Boucher, Lupton, & Watson, 2000), while
functional play is correlated with expressive language level
in preschool age children (Lewis et al., 2000). Longitudinal
studies have also demonstrated a relation between early
play skills and later language ability (McCune, 1995;
Ungerer & Sigman, 1984). Ungerer and Sigman (1984)
demonstrated that functional play at 13 months correlated
with language ability at 22 months. Bates et al. (1979)
found that both combinatorial (i.e., manipulative) and
symbolic play correlated with gains in language from 9 to
13 months of age, with manipulative play predicting both
receptive and expressive language abilities through the
9–13 month period, while symbolic play was related more
to expressive language and was a stronger predictor toward
the end of the 9–13 month period. McCune (1995) dem-
onstrated that first word acquisition was associated with the
emergence of symbolic play, both self-pretend (e.g.,
drinking from an empty cup) and other-pretend play (e.g.,
giving a stuffed animal a drink), and that combining
actions in symbolic play (e.g., drinking from an empty cup,
then giving a doll a drink) was associated with the onset of
combining words.
In contrast to typically developing children, children
with autism show specific impairments in symbolic play as
early as 18 months of age relative to children with delayed
and typical development (Baron-Cohen et al., 1996;
Charman et al., 1998; Dawson et al., 1998; Mundy et al.,
1987; Ungerer & Sigman, 1981; Wing & Gould, 1979).
When children with autism do acquire symbolic play skills,
their level of symbolic play tends to remain below that of
their language level (Amato, Barrow, & Domingo, 1999;
Ungerer, 1989; Wing, 1978) and is often less diverse and
elaborate compared to that of developmentally delayed and
typical children (Ungerer & Sigman, 1981). Associations
between play and language have also been demonstrated in
young children with autism. Mundy et al. (1987) found
that, at 3–6 years of age, receptive language ability cor-
related with functional play involving a doll, and both
expressive and receptive language skills correlated with
symbolic play. Sigman and Ruskin (1999) demonstrated
that, in 3–6-year-old children with autism, both functional
and symbolic play in early childhood correlated with early
language ability, and functional play correlated with long-
term (i.e., 8–9 years later) gains in expressive language. A
recent intervention study that targeted symbolic play skills
found that young children with autism showed greater
gains in language 12 months post-treatment compared to
controls (Kasari et al., 2004).
Although correlational and longitudinal research have
demonstrated that joint attention, imitation, and play are
associated with the development of language and com-
munication skills in children with autism, the present
study represents a unique contribution in two ways: First,
the contributions of each of these three early abili-
ties—joint attention, imitation, and toy play—were
simultaneously examined as predictors of current lan-
guage ability in a large sample of preschool age children
with autism. Second, growth curve modeling was used to
examine the relationship between these early skills and
rate of development of communication skills across the
preschool and early school age years in children with
autism.
Method
Participants
Sixty children with autism spectrum disorder (ASD),
comprised of 42 children with Autistic Disorder and 18
children with Pervasive Developmental Disorder, Not
Otherwise Specified (PDD-NOS), participated in the study.
Participants were recruited from local parent advocacy
groups, public schools, clinics, hospitals, and the
Washington State Division of Developmental Disabilities.
Exclusionary criteria included the presence of a neurolog-
ical disorder of known etiology, significant sensory or
motor impairment, major physical abnormalities, and his-
tory of serious head injury and/or neurological disease.
Table 1 presents demographic and descriptive information,
including gender, socioeconomic status, chronological age,
composite mental age and IQ, and verbal age equivalents
for the children who participated in the study. At the
beginning of the study, children ranged in age from 34 to
52 months and were followed until 65 to 78 months of age.
Ethnicity for the sample was as follows: 43 European-
American, 3 African-American, 11 Multi-racial, and 3
Asian/Pacific Islander. Twelve children (20%) displayed an
expressive language age equivalence of 36 months or
higher on the Mullen Scales of Early Learning. Based on
the ADI-R, 20 children were reported to have lost some
level of spontaneous, meaningful communicative speech.
J Autism Dev Disord (2006) 36:993–1005 995
123
Eighty-two percent of mothers had some college or a col-
lege degree.
Diagnosis of autism was based on the Autism Diag-
nostic Interview—Revised (ADI-R; LeCouteur, Lord, &
Rutter, 2003; Lord, Rutter, & LeCouteur, 1994) and the
Autism Diagnostic Observation Schedule (ADOS; Lord
et al., 2000; Lord, Rutter, DiLavore, & Risi, 1999; Lord,
Rutter, Goode, & Heemsbergen, 1989). Both instruments
assess the symptoms of Autistic Disorder listed in the
Diagnostic and Statistical Manual of Mental Disorders, 4th
ed. (DSM-IV; American Psychiatric Association, 1994). In
addition, clinicians made a clinical judgment of diagnosis
based on presence/absence of autism spectrum symptoms
as defined in the DSM-IV. Diagnosis of autism was defined
as meeting criteria for autism on the ADOS and autism
spectrum on the ADI-R and meeting DSM-IV criteria for
Autistic Disorder based on clinical judgment. In addition, if
a child received a diagnosis of autism on the ADOS and
based on DSM-IV clinical diagnosis, and came within 2
points of meeting autism spectrum criteria on the ADI-R,
the child was also considered to have autism. Diagnosis of
PDD-NOS was defined as meeting criteria for autism
spectrum on the ADOS and on the ADI-R, or missing
criteria on the ADI-R by 2 or fewer points, and meeting
DSM-IV criteria for PDD-NOS based on clinical judgment.
Procedure
The following measures were gathered over the course of
three or more sessions when children were 3–4 years old.
Each child was individually tested while seated at a table.
The child’s parent remained in the room, seated behind the
child or at the table with the child on the parent’s lap.
Children were given food snacks and praise as reward for
sitting at the table when necessary and provided breaks as
needed. The ADOS, ADI-R, and Mullen Scales of Early
Learning: AGS Edition (Mullen, 1997) were administered
during the child’s first laboratory visit, the Early Social
Communication Scales (ESCS) was administered during
the second visit, and experimental assessments of imitation
and functional and symbolic toy play were administered
during subsequent visits. The Vineland Adaptive Behavior
Scales: Survey Form (Sparrow, Balla, & Cicchetti, 1984)
was administered to the parent(s) in person when the child
was 3–4 years of age, and every 6 months thereafter by
phone up to 6 years, 6 months of age.
Predictor Variables
The Early Social Communication Scales (ESCS; Mundy,
Delgado, Hogan, & Doehring, 2003; Seibert & Hogan,
1982) was used to measure both protodeclarative and
protoimperative joint attention behaviors. In this proce-
dure, the child was seated at a table across from a familiar
examiner. A set of toys including a hat, comb, pair of
glasses, book, ball, car, wind-up and hand-operated toys,
and a plastic jar was in view, but out of reach of the child.
Three wall posters hung 90 degrees to the child’s right and
left, and 180 degrees behind the child. The examiner pre-
sented a sequence of wind-up and hand-operated toys,
activating each three times per trial (6 trials). Intermit-
tently, the examiner attracted the child’s attention, then
turned to point and gaze at each poster while calling the
child’s name three times (2 trials of 3 probes each), made
simple gestural and verbal requests of the child (‘‘Give it to
me’’), and presented the child with turn-taking opportuni-
ties, consisting of a tickle game (2 trials), taking turns with
an object (2 trials), and taking turns wearing a hat, comb,
and glasses (3 trials). The examiner also gave the child the
opportunity to look at pictures in a book and follow the
examiner’s point (1 trial). This 20-min structured assess-
ment was videotaped from behind a one-way mirror to
include a full view of the child and a profile view of the
examiner. Behavioral ratings were made from the video-
tapes by trained observers blind with respect to diagnosis
(these same observers also coded tapes of children with
delayed and typical development as part of a larger study)
and hypotheses. A more complete discussion of the ESCS
procedure is available elsewhere (Mundy et al., 2003).
Initiating and Responding to Protodeclarative Joint
Attention
Behavioral observations from the 20-min ESCS procedure
yielded scores in two categories of protodeclarative joint
attention. Initiating Protodeclarative Joint Attention could
Table 1 Sample characteristics
a
N M:F SES+ CA (mos) Mullen Composite MA (mos) Mullen
Composite IQ Mullen Verbal AE (mos)
b
60 51:9 46.2 43.6 25.4 58.1 22.9
SD (11.2) (4.3) (8.6) (19.8) (10.3)
Range 22–66 34–52 11.8–46.8 30–101 8–50
a
Numbers in the first row represent means; second row, standard
deviations (SDs) in parentheses; third row, range
b
The Mullen verbal age equivalent is the average of the Mullen
receptive language and Mullen expressive language age
equivalents
996 J Autism Dev Disord (2006) 36:993–1005
123
occur at any time during the assessment and consisted of
the number of times the child used eye gaze, alternating
eye gaze, showing, and/or pointing behaviors to direct and/
or share attention with the examiner with respect to an
active toy. Responding to Protodeclarative Joint Attention
was the percentage of six trials on which the child accu-
rately oriented with eyes and/or head turn beyond the
examiner’s finger and in the direction of the examiner’s
point and gaze to the posters.
Initiating Protoimperative Joint Attention
A frequency score was obtained for Initiating Protoim-
perative Joint Attention based on observations from the
ESCS, which could occur at any time during the assess-
ment and consisted of the number of times the child used
eye gaze, reaching with coordinated eye gaze, pointing,
and/or giving to request a toy or to request help. Dyadic
behaviors (e.g., a reach without coordinated eye contact)
were not included in this category.
Reliability of the behavioral coding of the ESCS task
occurred in two phases. First, initial reliability was
assessed by independent paired ratings using 15 taped
ESCS sessions provided by Peter Mundy. Each of five
raters (undergraduate research assistants) independently
coded the 15 tapes and these ratings were then compared to
those obtained by Peter Mundy using intra-class correlation
coefficients. The coefficients for the three variables used in
the present study—initiating and responding to protode-
clarative joint attention and initiating protoimperative joint
attention—ranged from .83 to .94. After achieving this
initial reliability, the five raters then began coding data for
the study using a detailed coding manual developed by the
first author based on conversations with Mundy and staff
that occurred during the process of obtaining initial reli-
ability. A second phase of reliability was assessed using
independent paired ratings made from videotapes for a
randomly selected group of participants (10% of total
sample). Intra-class correlation coefficients for this second
phase of reliability were .80 for initiating protodeclarative
joint attention, .75 for responding to protodeclarative joint
attention, and .86 for initiating protoimperative joint
attention.
Imitation and Deferred Imitation
Immediate and deferred motor imitation abilities were
assessed based on a battery developed by Meltzoff (1988a,
b) and previously used with children with autism (Dawson
et al., 1998) and Down syndrome (Rast & Meltzoff, 1995).
The battery consisted of 10 motor imitation items admin-
istered in 2 blocks, 5 immediate and 5 deferred. Items
involved simple actions on novel objects, such as pressing
a light panel with one’s forehead, hitting two red blocks
together, and inverting and collapsing a camping cup.
Block order was counterbalanced and order of presentation
of specific items within each block was randomly deter-
mined. The child was seated at a table across from a
familiar examiner. After gaining the child’s attention, the
examiner demonstrated each target action 3 times in about
20 s. In the immediate condition, after demonstrating all
5 actions, the examiner then handed the object(s) to the
child one at a time and said, ‘‘It’s your turn.’’ No other
verbal or physical prompts were used to elicit a response.
In the deferred condition, after demonstrating all 5 actions,
a 10-min delay was introduced during which the child was
escorted out of the test room. After the delay, the child
returned to the test room and the examiner handed the
object(s) to the child one at a time and said, ‘‘Here’s a toy
for you to play with.’’ In both conditions, the child’s
behavior was coded during a test period of 20 seconds,
which began from the time the child first touched the
object(s). Behavioral ratings were made live by a trained
clinician and from an immediate review of the videotapes
when a judgment could not be made live (this occurred
infrequently). The same clinician administered this mea-
sure to all children in the study. The dependent measure
was the total number of acts imitated, ranging from 0 to 5
for each condition. Intra- and inter-observer agreement
were both high. Intra-observer agreement was assessed by
having the initial coder rescore a randomly selected 10% of
the children from videotape. The coder waited more than
4 months after the first coding and was uninformed as to
the initial scoring. For the inter-observer assessment, a
second independent coder reviewed the videotapes of the
same randomly selected children, while remaining unin-
formed as to the initial scoring. There were few disagree-
ments: Intra- and inter-observer agreement, as assessed by
Pearson rs, were respectively .99 and .99 for immediate
imitation and 1.00 and .96 for deferred imitation.
Toy Play
In this structured assessment of functional and symbolic
toy play skills, the child was seated at a table across from
a familiar examiner. Six dolls and sets of stimuli, func-
tional and representational, were presented to the child
one at a time, with functional and symbolic conditions (3
dolls and sets of stimuli per condition) counterbalanced
across participants. Representational stimuli included a
block to represent a sandwich, a plastic lid and bag to
represent a blanket and pillow, a tongue depressor to
represent a comb, a small plastic object to represent a
cup, a shoebox to represent a bathtub, and a blue wooden
J Autism Dev Disord (2006) 36:993–1005 997
123
cylinder to represent a toothbrush. Functional objects for
each of these (e.g., a plastic sandwich, a comb, etc.) were
also included. For each condition, the child was presented
with a doll and object(s) and told, ‘‘You can play with
these.’’ Every 20 seconds, if the child was playing with
only some of the toys or not at all, the examiner repeated
the statement, ‘‘You can play with all of these’’ and
gestured to all of the toys. No further verbal or physical
prompts were provided. After 1 min, the toys were
removed from the table and the next doll and object(s)
were presented. The dolls were first presented unprompted
for each condition. For any target actions not performed
by the child, prompted trials were then given. Prompted
trials consisted of a verbal and gestural prompt, such as
‘‘Wally is hungry, give him a sandwich’’ while the
examiner patted her own stomach, but the examiner did
not model the target action on the doll. The child’s re-
sponses were scored in the following way: target action
was performed on the doll, on self, or on another person
(both prompted and unprompted trials were credited a
score of ‘1’ if the target action was performed); another
symbolic action was performed to self or other (these
actions were not included in the score); target action was
not performed (score of ‘0’). Functional and symbolic
play were highly correlated in this sample (r = .68) and
were therefore summed together to create one total play
score ranging from 0 to 6 (score of 0–3 possible for
functional play acts and 0–3 for symbolic play acts). The
same clinician administered this measure to all children in
the study. Behavioral ratings were made live by a trained
clinician (and in a few instances of ambiguity from
immediate review of the videotapes). Intra-observer
agreement was assessed by having the initial coder re-
score a randomly selected 10% of the children from
videotape (more than 4 months after the first coding,
while remaining uninformed as to the first judgments).
For the inter-observer assessment, a second independent
coder reviewed the same videotapes while uninformed as
to the initial scoring. Intra- and inter-observer agreement
for the total play score were, respectively, r = .97and .96.
Language Measures
Mullen Scales of Early Learning: AGS Edition
Receptive and expressive language age equivalents and
standard scores were derived from subscales of the Mullen
Scales of Early Learning (Mullen, 1997), which is a stan-
dardized measure of cognitive function for infants and
preschool age children. The Mullen was administered to
each child at age 3–4 years to obtain a measure of overall
cognitive ability as well as separate scores for both
receptive and expressive language abilities.
Vineland Adaptive Behavior Scales: Survey Form
The Vineland Adaptive Behavior Scales (Sparrow et al.,
1984) is a standardized parent interview that includes
assessment of communication skills (i.e., receptive,
expressive, and written communication). The Vineland was
administered by phone every 6 months from age 3–4 to
6.5 years. Although the Vineland norms were based on in-
person administration of the instrument, the decision was
made to administer the Vineland by phone for this sample
in order to lessen the burden on parents. Interviewers were
blind to the Vineland responses obtained previously, and
each time the Vineland was administered, a new basal and
ceiling were obtained. In addition, the same parent was
interviewed at each time point. Interviewers followed the
procedure as outlined in the Vineland manual, beginning
with a broad interview format followed by more targeted
questions to gather the information necessary to score each
item. The overall communication subscale age equivalent
score every 6 months up to 6.5 years of age was used in
growth curve analyses, with an average of 6 data points per
child. Age equivalent scores were chosen over raw scores
as they provide a more meaningful metric with which to
interpret change over time (i.e., increase in months rather
than Vineland points). Communication ability as assessed
by the Vineland was highly correlated with language
ability as assessed by standardized language tests, both at
the outset of the study and at final follow-up at age 6 years.
This suggests that, for this sample, Vineland communica-
tion scores were a reasonably good measure of receptive
and expressive language ability. At age 3–4 years, the
Mullen verbal age equivalent and the Vineland communi-
cation age equivalent were correlated .78 (Vineland and
Mullen receptive language age equivalents were correlated
.48, and Vineland and Mullen expressive language age
equivalents were correlated .81). At age 6 years, the
Vineland communication standard score and the verbal
standard score as measured by the Differential Ability
Scales (DAS) were correlated .72.
Results
Means, standard deviations (SD), and ranges for the pre-
dictor variables are presented in Table 2. Correlations
among predictor variables were moderate, ranging from .20
to .67 (Table 3). The various language variables used in the
regression analyses were highly correlated with each other
(r = .89–.97 among Mullen variables, and .71–.79 between
Mullen and Vineland variables). Correlations between
predictor variables and initial language ability are shown in
Table 4. To determine the unique contributions of each of
the predictor variables to concurrent language, multiple
998 J Autism Dev Disord (2006) 36:993–1005
123
regression analyses were conducted. Although predictors
were moderately correlated with one another, multicollin-
earity diagnostics indicated adequate tolerance levels.
Contributions of Joint Attention, Imitation, and Toy
Play to Language Ability at Age 3–4 years
Multiple regression analyses were conducted with all of the
predictor variables entered in one step, in which case
the test of the partial regressions weight controls for all the
other predictors in the model. Results are presented in
Table 5 and indicate that across a range of language
variables—receptive and expressive language, parent
report and direct observation—initiating protodeclarative
joint attention and immediate imitation were most strongly
associated with concurrent language ability in 3–4-year-old
children with autism.
Predicting Rate of Communication Development
Next, to examine the degree to which these three early
abilities—joint attention, imitation, and toy play—
accounted for the variability in rate of communication
development over the preschool and early school age per-
iod, growth trajectories using repeated Vineland measure-
ments were modeled using Hierarchical Linear Modeling
(HLM; Raudenbush & Bryk, 2002) with two parameters,
an intercept (absolute communication level at 48 months)
and a linear slope.
1
Time was thus coded in months and
centered around 48. The six individual predictor variables
were standardized and entered as predictors of individual
differences in the growth trajectories (both intercepts and
slopes). As shown in Table 6, immediate imitation and toy
play abilities were significantly related to individual dif-
ferences in children’s communication ability at 48 months
as measured with the Vineland, partially replicating results
examining predictors of early language using the Mullen
language scores reported above. (Note that the correlations
with the Mullen Language Scores were computed at entry
into the study when children were slightly younger, 3–4
years of age). The coefficients at the intercept indicate that
children whose immediate imitation ability was 1 SD
above the mean had communication scores over 3 months
higher than those at the sample mean, and children with toy
play ability 1 SD above the mean had communication
scores 3 months higher than those at the sample mean.
Examining individual differences in the slope (rate of
change), it was found that both toy play and deferred
imitation were significantly and positively related to rate of
acquisition of communication skills over the next 2 years
(see Fig. 1). The average rate of change for the sample was
.75, meaning that the sample as a whole showed 3
4
of a
month’s growth in communication ability for each chro-
nological month that passed. Two skills, toy play and
deferred imitation, were related to rate of change. Children
who had toy play scores 1 SD above the sample mean
(while controlling for all other variables) showed a rate of
change of .91 month/chronological month (or 11 months
for every year), whereas children with toy play scores 1 SD
below the sample mean had a rate of change of only
.59 month/chronological month (7 months for every year).
Similarly, children with deferred imitation scores 1 SD
above the sample mean showed a rate of change of
.96 month/chronological month (11.5 months per year),
whereas children with deferred imitation scores 1 SD
below the sample mean had a rate of change of only
.54 month/chronological month (6.5 months per year).
Inasmuch as both these variables—toy play and deferred
imitation—predicted unique variability in the rate of
change, their additive effect was even greater. Thus, the
combination of better toy play ability and more developed
deferred imitation skills was associated with faster rates of
change in communication skills across the preschool and
early school age period. These positive associations
Table 2 Descriptive statistics for predictor variables
Predictor M (SD) Range
Init Protodecl JA
a
7.9 (8.7) 0–43
Resp Protodecl JA (%)
b
.51 (.35) 0–1 (%)
Init Protoimp JA
c
11.2 (8.8) 0–36
Imitation-Immediate
d
2.9 (1.7) 0–5
Imitation-Deferred
e
1.9 (1.6) 0–5
Toy Play
f
4.0 (2.2) 0–6
a
Initiating protodeclarative joint attention was a frequency score
consisting of the number of times the child used eye gaze,
alternating
eye gaze, showing, and/or pointing behaviors to direct and/or
share
attention with the examiner with respect to an active toy
b
Responding to protodeclarative joint attention was the
percentage of
six trials on which the child accurately oriented with eyes
and/or head
turn beyond the examiner’s finger and in the direction of the
exam-
iner’s point and gaze to the posters
c
Initiating protoimperative joint attention was a frequency score
consisting of the number of times the child used eye gaze,
reached
with coordinated eye gaze, gave objects, and/or pointed to
request a
toy or to request help
d
Immediate imitation consisted of the total number of immediate
imitation items imitated
e
Deferred imitation consisted of the total number of deferred
imitation
items imitated
f
Toy play consisted of the number of functional and symbolic
play
acts performed, prompted or unprompted
1
An unconditional model with both linear and quadratic terms
was
also run. The quadratic term in this model was not significantly
dif-
ferent from zero (coeff. = .001134, std error = .0031, t(59) =
.365,
P = .716) and showed much less variability than the linear term
(variance component: linear term = .34247, quadratic term =
.00025), thus the model with the single linear slope was deemed
most
appropriate for these data.
J Autism Dev Disord (2006) 36:993–1005 999
123
remained for deferred imitation (t = 2.07, P < .05) and
nearly so for toy play (t = 1.81, P = .076) even after
controlling for child IQ.
Discussion
One purpose of the present study was to better understand
the contributions of each of three early abilities—joint
attention, imitation, and toy play—to early language ability
in young children with autism. Previous studies have pri-
marily demonstrated correlations between each of these
skill domains, and early and later language ability in
children with autism. In the present study, when these three
abilities were examined simultaneously, initiating
protodeclarative joint attention and immediate imitation
abilities were most strongly associated with language skills
in 3–4-year-old children with autism.
Table 6 HLM growth curve
analyses predicting rate of
acquisition of communicative
skills in young children with
autism
Intercept is Vineland
communication score at
48 months; *P < .05,
**P < .01
Intercept (48 mos.) Slope (Rate of change)
Coeff t Coeff t
Constant 22.61 27.95** .75 14.34**
Joint attention—protodeclarative
Initiate 1.10 1.20 –.06 –1.27
Respond 1.30 1.10 .03 .38
Joint attention—protoimperative
Initiate –1.28 –1.29 –.01 –.11
Imitation objects
Immediate 3.20 3.47** –.01 –.80
Deferred 2.08 1.61 .21* 2.61*
Toy Play 3.02 2.54* .16* 2.34*
Table 3 Correlations among predictor variables: joint attention,
imitation, and toy play
Init Protodecl JA Resp Protodecl JA Init Protoimp JA Symbolic
Play Imitation immediate Imitation deferred
Functional Play .31* .51*** .23 .67*** .43** .41**
Init Protodecl JA .43** .39** .48*** .28* .45***
Resp Protodecl JA .38** .58*** .44*** .66***
Init Protoimp JA .24 .20 .20
Symbolic Play .37** .50***
Imitation-Immediate .53***
*P < .05, **P < .01, ***P < .001
Table 4 Relations between joint attention, imitation, and toy
play, and language ability
Init Protodecl JA Resp Protodecl JA Init Protoimp JA Toy Play
Immediate imitation Deferred imitation
Mullen Verbal AE .53** .60** .23 .54** .66** .67**
Mullen Rec Lang AE .49** .58** .20 .50** .64** .66**
Mullen Expr Lang AE .53** .59** .25
a
.56** .64** .63**
Vineland Comm AE .53** .62** .30* .51** .56** .65**
*P < .05, **P < .001
a
P = .05
Table 5 Relations between joint attention, imitation, and toy
play, and current language ability in 3–4-year-old children with
autism
Mullen Verbal AE Mullen Rec Lang AE Mullen Expr Lang AE
Vineland Comm AE
Init Protodecl JA .25* .23* .25* .25*
Resp Protodecl JA .16 .16 .15 .23
Init Protoimp JA –.06 –.08 –.04 .02
Toy play .08 .03 .12 –.02
Imitation immediate .39*** .38** .37** .26*
Imitation deferred .22 .26* .17 .26
Total R
2
.65 .62 .62 .58
Numbers are standardized betas; *P < .05, **P < .01, ***P <
.001
1000 J Autism Dev Disord (2006) 36:993–1005
123
A second aim of this study was to better understand the
relationship between these early skills and rate of acqui-
sition of communication skills during the preschool and
early school age years in children with autism. Using
growth curve modeling, it was found that toy play and
deferred imitation were associated with higher rates of
acquisition of communication skills between 4 and
6.5 years of age. That is, children with autism who had
better toy play and deferred imitation abilities at age 4
acquired communication skills at a faster rate than those
with less developed toy play and deferred imitation skills.
For example, children who performed 1 SD above the
sample mean in both toy play and deferred imitation skills
had communication acquisition rates that were comparable
to typical children (13.4 months of communication growth
per 1 year of chronological age). (However, because the
children with autism started out at a lower level, their
language skills were still below age level at outcome.) In
comparison, children who performed 1 SD below the mean
in both toy play and deferred imitation skills acquired
communication skills at a rate of only 4.5 months per
1 year of chronological age.
These findings have important implications for under-
standing the nature and course of language development in
autism, and for designing targeted early interventions.
While initiating protodeclarative joint attention and
immediate imitation contributed to language ability at the
outset, toy play and deferred imitation were predictive of
rate of development of communication skills over the next
few years. These findings suggest that while all three
abilities might be important for laying a foundation for
language development in autism, toy play and deferred
imitation skills might contribute to the continued expansion
of language and communication skills over the preschool
and early school age period. This is not to suggest that joint
attention is not related to later language ability in autism.
Children with stronger joint attention skills also began with
better language at 3–4 years of age. That is, our findings
showed that children with better-developed initial joint
attention skills also had better-developed initial language
ability, and these children continued to show higher lan-
guage and communication skills across the preschool and
early school age years. Overall, however, when joint
attention was examined together with imitation and toy
play, only deferred imitation and toy play remained sig-
nificantly associated with rate (i.e., slope) of change in
communication skills over time.
We can speculate that joint attention and immediate
imitation are important ‘‘starter set’’ skills that set the
stage for social and communicative exchanges in which
language can develop, as described in the introduction.
Once this stage is set and the child begins to learn to use
language in a communicative manner, representational
skills become important in the continued acquisition of
words and phrases during the preschool and early school
age period. Toy play and deferred imitation abilities often
involve shared attention, but they also index higher level
cognitive skills that are important for the continued
development and expansion of language and social com-
munication abilities: an active interest, curiosity in, and
exploration of the environment; representational thought,
memory; and cognitive planning. While joint attention
episodes occur in a social context, both toy play (particu-
larly as it was measured here with dolls) and deferred
imitation require that the child actively attend to the
immediate environment, observe the events and actions
taking place, then reproduce these events and socially-
mediated actions at a later time. The ability to demonstrate
these skills requires an active interest in people and/or
things (capturing the child’s attention), representational
thinking (forming and storing a mental representation),
intact recall memory (calling up that representation at a
later time), and both cognitive and motor planning skills in
order to reproduce the action or event (Klein & Meltzoff,
1999; Meltzoff, 1988b, 1999). Additionally, the child’s
ability to reproduce actions at a later time reflects not only
symbolic thinking and intact recall memory, but also a
‘‘shared attitude toward objects,’’ as the child demonstrates
the same actions on objects that he has witnessed of others
(Meltzoff, 2005; Meltzoff & Gopnik, 1993). Thus, through
toy play and imitation, the child not only comes to an
understanding of the world around him—what people do
and think and how objects work—but also has the oppor-
tunity to demonstrate that understanding.
The results of the present study also have implications
for early intervention. All three skill domains—joint
attention, imitation, and toy play—are related to the
development of language and communication abilities in
young children with autism and are therefore important
Child's Age in Months
45 50 55 60 65 70 75 80
V
in
e
la
n
d
C
o
m
m
u
n
ic
a
tio
n
A
g
e
E
q
u
iv
a
le
n
ce
10
20
30
40
50
60
70
Mea
n tra
jecto
ry
Toy
Pla
y, D
efe
rred
Imi
tati
on
+1
SD
Toy Play
, Deferre
d Imitatio
n -1 SD
Nor
mat
ive
gro
wth
Fig. 1 Comparison of rates of acquisition of communication
skills in
children with autism who have toy play and imitation skills
either
1 SD above, or 1 SD below, the sample mean
J Autism Dev Disord (2006) 36:993–1005 1001
123
targets for early intervention. A number of studies have
shown promising results in facilitating the development of
joint attention in children with autism (Klinger & Dawson,
1992; Siller & Sigman, 2002; Whalen & Schreibman,
2003). Kasari et al. (2004) recently conducted a treatment
study that examined two interventions, one that targeted
joint attention skills and one that targeted play skills. The
play intervention focused not only on symbolic acts, but
also overall level of play. Children with autism were ran-
domly assigned to one of three groups—the joint attention
treatment group, the play treatment group, or the control
group—upon admission to the program. The control group
participated in a general early intervention program.
Results showed that children in the joint attention inter-
vention group showed significantly more pointing and
showing, more responses to joint attention, and more child-
initiated joint attention in mother–child interactions than at
pre-treatment. Similarly, children in the play group showed
significantly greater frequencies and types of play acts and
higher play levels on both a structured play assessment and
during mother–child interactions than at pre-treatment.
Further, over a 14-month period, the two experimental
groups showed an average of 15–17 months gain in
expressive language ability compared to only 7.5 months
for the control group. Although this study did not examine
pre-treatment differences among groups on a range of
variables, the results demonstrate that skills such as joint
attention and play may be modified and may contribute to
gains in other skill areas, such as expressive language
ability, in children with autism.
Another treatment study examined the behavioral pro-
files of responders and non-responders to Pivotal Response
Training (PRT) (Sherer & Schreibman, 2004 in press).
Children with responder profiles tended to have better-
developed toy play skills at pre-treatment, demonstrated
greater gains in language, play, and social skills during
treatment sessions than non-responders, and also general-
ized these skills to no-treatment environments and
untrained stimuli. Although the study design used in the
Sherer and Schreibman study precludes conclusions as to
whether improvement occurred in response to treatment or
in response to treatment plus other factors, it does tell us
that certain skills, such as toy play skills, might influence
the acquisition of language and other abilities that are
targeted in the treatment of children with autism.
It should be noted that due to the wide heterogeneity in
language skills in autism, meaningful speech, that is,
speech that is frequent or consistent, referential, and
communicative, is difficult to assess with any one measure.
Standardized cognitive tests sample behavior over the
course of 1 h, while parent report measures such as the
Vineland provide a summary of behavior over a broader
time frame and range of settings. Each of these measures
captures some, but not all, aspects of meaningful commu-
nication. In the current study, the Vineland was shown to
be highly correlated with direct assessment of language in
this sample, and was therefore deemed a suitable measure
of rate of language acquisition over time in young children
with autism. The Vineland also allowed for a repeated
measure appropriate for growth curve analysis that was not
confounded by test practice effects. The broader issue of
what measure best captures meaningful or useful speech
remains an important one, but one that lies outside the
scope of this study.
In summary, the results of the present study shed light
on the relationship between early skill domains and the
development of language and communication in young
children with autism, and suggest specific targets for early
intervention. Early abilities involved in social exchange
and communication, namely, joint attention and immediate
imitation, appear to be important for setting the stage for
early language learning in autism, while representational
skills, demonstrated through toy play and deferred imita-
tion, contribute to the continued expansion of language and
communication skills over the preschool and early school
age years. Each of these skill areas represents an important
target for early intervention programs that promote com-
municative competence and improved outcomes for young
children with autism.
Acknowledgments This research was funded by a program
project
grant from the National Institute of Child Health and Human
Development and the National Institute on Deafness and
Communi-
cation Disability (U19HD35465), which is part of the
NICHD/NID-
CD Collaborative Program of Excellence in Autism and by a
center
grant from the National Institute of Mental Health
(U54MH066399),
which is part of the NIH Studies to Advance Autism Research
and
Treatment (STAART) Centers Program. We gratefully
acknowledge
the contributions of the parents and their children who
participated in
this study and several other people who made significant
contributions
to this research: Craig Harris and several undergraduate
research
assistants.
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123
Working Memory and Specific Language
Impairment: An Update on the Relation and
Perspectives on Assessment and Treatment
James W. Montgomery
Beula M. Magimairaj
Mianisha C. Finney
Ohio University, Athens
Purpose: Children with specific language im-
pairment (SLI) demonstrate significant language
impairments despite normal-range hearing and
nonverbal IQ. Many of these children also show
marked deficits in working memory (WM) abilities.
However, the theoretical and clinical character-
ization of the association between WM and
language limitations in SLI is still sparse. Our
understanding of this association would benefit
greatly from an updated and thorough review of
the literature.
Method: We review the newest developments in
these areas from both a theoretical and clinical
perspective. Our intent is to provide researchers
and practicing clinicians (a) a conceptual frame-
work within which the association between WM
and language limitations of children with SLI
can be understood and (b) potentially helpful
suggestions for assessing and treating the
memory-language difficulties of children with SLI.
Conclusions: In the past 10 years, important
new theoretical insights into the range and nature
of WM deficits and relation between these
limitations and the language difficulties in SLI
have occurred. New, robust diagnostic assess-
ment tools and computerized treatment methods
designed to enhance children’s WM functioning
have also been developed. The assessment,
diagnosis, and treatment of the language diffi-
culties in SLI should consider the potential
influence of WM.
Key Words: children, specific language
impairment, working memory, language
M
any children with specific language impairment
(SLI) exhibit significant working memory (WM)
deficits relative to same-age peers. In 2002,
Montgomery published a review article on what was known
about the WM deficits of children with SLI and the relation
of these deficits to these children’s language problems. Since
then, new and important insights into WM and language in
children with SLI and typically developing (TD) children
have occurred. We review these new developments. We cast
the WM deficits and their relation to SLI in broad theoretical
terms, which allows us to contextualize the WM issues
defining the current SLI literature. During this same period,
new WM assessment tools and computerized training meth-
ods designed to remediate the WM deficiencies of children
have been developed. Many of these tools are available to
the practicing speech-language pathologist (SLP). These new
developments and their clinical relevance to SLI will be
reviewed.
Children with SLI demonstrate normal-range hearing and
nonverbal intelligence and an absence of developmental
disability (e.g., autism or fragile X syndrome) yet marked
expressive and/or receptive language difficulties for their
age. Many children with SLI also exhibit limitations in WM.
WM refers to the mental processes allowing limited infor-
mation to be held in a temporary accessible state during
cognitive processing (Cowan, Nugent, Elliott, Ponomarev, &
Saults, 2005); that is, WM involves concurrent informa-
tion processing and storage. Because WM is considered a
primitive of higher level cognition (e.g., Unsworth & Engle,
2007), including fluid intelligence, language learning/
performance, and academic learning, it is important to un-
derstand its nature. The WM system includes various mech-
anisms and properties. Over the past decade, the range of
WM problems exhibited by children with SLI has broadened,
and the evidence implicating an association between the WM
and language difficulties in children with SLI has grown.
This said, it should be noted that children with SLI repre-
sent a heterogeneous population not only with respect to the
linguistic deficits they exhibit (Leonard, 1998) but also as to
whether they demonstrate WM limitations. Although WM
Tutorial
American Journal of Speech-Language Pathology • Vol. 19 •
78–94 • February 2010 • A American Speech-Language-Hearing
Association78
limitations characterize many children with SLI, not all chil-
dren with SLI evidence such deficits (Archibald & Joanisse,
2009). The information in the present article reflects what
is known about children with SLI who do demonstrate WM
problems.
WM in TD Children
A Theoretical Backdrop
To better understand the SLI literature, it is important to
have some familiarity with the key issues defining the re-
cent developmental memory literature. The majority of WM
research has been conducted within Baddeley’s original
tripartite framework (Baddeley & Hitch, 1974). This model
describes WM as a multidimensional system comprising
three separable yet interactive mechanisms (Bayliss, Jarrold,
Baddeley, Gunn, & Leigh, 2005; Gathercole, 1999; Gavens
& Barrouillet, 2004; Towse, Hitch, & Hutton, 1998). One is
a domain-general central executive responsible for coordi-
nating and controlling the different activities within WM.
The executive has finite attentional resources (mental energy/
capacity) that are controlled in a flexible manner. Attentional
control is key, and its regulatory functions include such
things as allocation (the ability to devote mental energy to
different levels of a task), updating (changing the contents
of WM through attention switching), sustained attention
(the ability to attend selectively to a stimulus in the midst of
interference), and inhibition (the ability to block irrelevant
stimuli from WM or focus of attention; Baddeley, 1996;
Barkley, 1996; Lehto, Juujarvi, Kooistra, & Pulkkinen, 2003).
The executive is roughly similar to the view of WM espoused
by Cowan (Cowan, 1997; Cowan et al., 2005) as the acti-
vation of a subset of representations (e.g., words) stored in
long-term memory that momentarily occupy the focus of
attention, and by Engle (Engle & Kane, 2004; Unsworth &
Engle, 2007) as attentional capacity and control.
The second and third mechanisms correspond to two
domain-specific storage devices, one devoted to the tempo-
rary retention of verbal material, the phonological loop, and
the other to visuospatial input, the visuospatial sketchpad.
In this article, we focus on the loop, hereafter referred to as
phonological short-term memory (pSTM). Recently, Baddeley
(2000, 2003) proposed a fourth mechanism, the episodic
buffer. The buffer is assumed to function as a temporary
storage device and a processing system capable of integrating
inputs from pSTM and the visuospatial sketchpad into a
coherent episode/representation. It is thought to be important
to the processing and retention of large chunks of language
material such as connected speech. Because the buffer is a
newly proposed mechanism, it does not enjoy the same theo-
retical specificity and empirical validation as the other com-
ponents (Baddeley, 2003). Finally, though not a mechanism,
developmental memory researchers have begun to examine
processing speed as an important property of WM and a
potential factor in defining the capacity limits of WM (Bayliss
et al., 2005; Towse & Hitch, 1995; Towse et al., 1998). In-
terest in speed derives from earlier work revealing reliable
intercorrelations among processing speed, short-term mem-
ory (STM), chronological age, and higher level cognitive
abilities (Fry & Hale, 1996, 2000; Gathercole & Baddeley,
1993; Kail, 1991). We are interested in processing speed
because of its emerging association with WM and central
focus in the SLI literature.
The basic architecture of the tripartite model—that is,
central executive, pSTM, and visuospatial STM—seems to
be developed by about age 6 (Gathercole, Pickering, Ambridge,
& Wearing, 2004). The capacity of each component increases
from early childhood into adolescence (Gathercole, 1999;
Gathercole et al., 2004). The executive is significantly linked
to both storage devices beginning in early childhood. This
finding indicates that the executive is associated with the
coordination of the flow of information throughout WM
(Baddeley, 1996; Gathercole et al., 2004), and different WM
mechanisms develop in an integrated fashion from an early
age. Finally, pSTM and visuospatial STM appear to develop
relatively independently of each other, revealing their domain-
specificity (Gathercole et al., 2004; Jarvis & Gathercole,
2003).
WM capacity is assessed using various concurrent
processing-storage tasks. In listening span tasks, children
listen to sets of sentences that increase in number (e.g.,
“Pumpkins are purple” and “Fish can swim”) and are asked
to respond to the truth value of each sentence (processing
component) and recall as many sentence-final words from
each set (storage component; Gathercole et al., 2004; Pickering
& Gathercole, 2001). In counting span tasks, children count
arrays of dots while remembering the sums of dots on each
array; at the end of a set, they recall the sums from each array.
In operation span tasks, children perform multiple arithmetic
problems, store the answer to each problem or a separate
word presented after each problem, and then recall all the
answers or words at the end of the set. The developmental
pattern is that processing accuracy is high while storage
significantly improves. WM capacity is typically indexed by
item recall—that is, availability of storage in the face of
processing/interference.
Much developmental work has focused on explaining
increases in children’s WM capacity, examining the roles of
the central executive and STM (Barrouillet & Camos, 2001;
Barouillet, Gavens, Vergauwe, Gaillard, & Camos, 2009;
Bayliss et al., 2005; Bayliss, Jarrold, Gunn, & Baddeley,
2003; Gathercole et al., 2004; Irwin-Chase & Burns, 2000;
Karatekin, 2004). Research has shown that gains in capacity
are associated with increases in both of these mechanisms.
Some researchers have investigated the impact of processing
speed/efficiency (Bayliss et al., 2005; Towse & Hitch, 1995;
Towse et al., 1998). The idea behind the association between
speed and WM capacity centers on the possibility that the
slower the processing activity of a WM task is completed, the
greater the opportunity for the stored items to decay or be
forgotten. Only recently have researchers begun to investi-
gate the collective contributions of STM and processing
speed on WM performance (Bayliss et al., 2003, 2005;
Magimairaj, Montgomery, Marinellie, & McCarthy, 2009).
Bayliss et al. (2005) examined the individual and combined
contributions of storage and processing speed on 6–10-year-
old children’s WM capacity. Hierarchical linear regression
and structural equation modeling showed that age-related
increases in STM and processing speed contributed to
Montgomery et al.: Working Memory and Language in SLI 79
developmental changes in WM capacity, with STM ac-
counting for greater variance than speed. Magimairaj et al.
(2009) replicated these findings in 6–12-year-old children.
Some have argued that increases in WM capacity may
also be driven by changes in attentional control. As children
grow older they become better at rapidly switching their
attention between the processing part of the task and remem-
bering the items in STM (Barrouillet et al., 2009; Conlin,
Gathercole, & Adams, 2005; Portrat, Camos, & Barrouillet,
2009). It is not difficult to see that attentional control (Engle,
2002; Unsworth & Engle, 2007) is closely related to the
idea of scope or focus of attention (Cowan, 1997; Cowan
et al., 2005) in that only a small bit of information can oc-
cupy the focus of attention at any given moment.
Relation of WM to Spoken Language Development
and Functioning
Lexical learning. Much developmental work investigat-
ing the relation between WM and language has centered on
word learning (Avons, Wragg, Cupples, & Lovegrove, 1998;
Gathercole & Baddeley, 1990b; Gathercole, Willis, Emslie,
& Baddeley, 1992). Most of this work has focused on pSTM,
which has been argued to function as an important language
learning device (Baddeley, Gathercole, & Papagno, 1998;
Gathercole, 2006; Gathercole & Baddeley, 1990b). Word
learning involves mapping sound to meaning. Using a variety
of methods, robust associations between pSTM and new
word learning have been reported for preschool-age children
through about age 8 (Bowey, 2001; Gathercole & Baddeley,
1989, 1990b; Gathercole, Service, Hitch, & Martin, 1997;
Jarrold, Thorn, & Stephens, 2009). The ability to hold novel
speech material in pSTM presumably permits children to
establish stable, long-term phonological representations of
new words in long-term memory (e.g., Jarrold et al., 2009).
As the lexicon grows, word entries become more phonolog-
ically refined and better organized, with one organizational
scheme involving words beginning with the same sound
being stored together (Luce & Pisoni, 1998). Phonological
STM and the ability to temporarily store new sound pat-
terns may be an important factor in young children’s lexical
learning and organization. Although the relation of pSTM
and word learning weakens after age 8 (Gathercole, 1995;
Gathercole, Tiffany, Briscoe, Thorn, & the ALSPAC Team,
2005), there continues to be a significant link through ado-
lescence into adulthood (Atkins & Baddeley, 1998; Gupta,
2003).
Morphological and syntactic learning and functioning.
Some researchers (Plunkett & Marchman, 1993; Tomasello,
2000) argue that young children do not possess morpho-
logical rules (e.g., past tense), grammatical categories (e.g.,
subjects, verbs, and objects), and syntactic structure (e.g.,
subject-verb-object [SVO] and passive). Rather, children
initially learn whole phrases and only later discover under-
lying rules, categories, and structures by using the distribu-
tional properties/regularities of the input (Nelson, 1987;
Plunkett & Marchman, 1993; Tomasello, 2000). Phonolog-
ical STM may serve as a mediating or moderating mecha-
nism for this analytic process. Some support for this idea
comes from Adams and Gathercole (1995), who reported
that pSTM predicts quantity and quality of spontaneous
speech in 3-year-old children. They showed that high-
pSTM capacity children, compared with low-capacity chil-
dren, produced longer utterances containing a greater range
of syntactic structures and lexical diversity. Blake, Austin,
Cannon, Lisus, and Vaughan (1994) showed that STM is a
better predictor of mean length of utterance in preschoolers
than chronological or mental age. Because morphological
and syntactic learning entails building relational knowledge,
it is likely that several executive functions are involved;
however, little empirical work has directly addressed the
issue.
The influence of WM capacity in language comprehen-
sion is only beginning to receive attention. At the sentence
level, the more controlled studies have focused on the relation
of WM and complex sentence comprehension. WM has been
linked to the comprehension of object relative clause forms
(e.g., “The hippo that the lion kissed on the nose was running
into the jungle”) in young children (Roberts, Marinis, Felser,
& Clahsen, 2007). Children with greater WM capacity show
more accurate comprehension than low-capacity children.
Comprehension minimally involves storing a prior element
(noun phrase [NP] 1) in WM while processing new, incoming
input. However, WM capacity is likely just one important
mechanism. Being able to reactivate a stored element and
then integrate it into a developing local structure in a timely
manner are other WM-related skills underlying complex
sentence comprehension (Lewis, Vasishth, & Van Dyke,
2006; McElree, Foraker, & Dyer, 2003; Van Dyke, 2007).
Support for this wider view comes from a recent study by
Montgomery, Magimairaj, and O’Malley (2008). These
authors showed that 6–12-year-old children’s spoken com-
prehension of verbal be passives (“The little girl was kissed
by the woman”) is associated with WM capacity and pro-
cessing speed. At a more global level, children’s comprehen-
sion of narrative is predicted by WM capacity and processing
speed (Montgomery, Polunenko, & Marinellie, 2009). Be-
cause narratives entail large amounts of input and keeping
track of many representations, developing a coherent mental
model requires the storage, retrieval, and rapid integration
of multiple representations across large stretches of input.
WM and Speed of Processing in SLI
Relative to age peers, many children with SLI show
significant limitations in nearly all WM mechanisms as well
as speed of processing (see Table 1). Appreciation of these
limitations and the relation of these limitations to the lan-
guage deficits of these children have important practical
implications. Such knowledge may translate into building
more informed clinical profiles of these children’s cognitive-
linguistic strengths and weaknesses. Such knowledge, in
turn, may help inform clinical assessment, diagnosis, and
treatment.
STM Storage
Many children with SLI show marked limitations in STM
capacity. Gathercole and Baddeley (1990b) proposed the
phonological storage deficit hypothesis of SLI, claiming that
80 American Journal of Speech-Language Pathology • Vol. 19 •
78–94 • February 2010
the language impairment in SLI is secondary to a deficit in
phonological storage. Phonological STM is assessed using
various tasks such as digit span, word span, and nonword
repetition. In digit and word span, children are presented
increasingly longer lists of items and recall each list in serial
order. In nonword repetition, children imitate nonwords
varying in length. Regardless of task, children with SLI gen-
erally exhibit reduced pSTM relative to age peers (Archibald
& Gathercole, 2006; Ellis Weismer et al., 2000; Gathercole
& Baddeley, 1990b; R. Gillam, Cowan, & Day, 1995;
Montgomery, 2004; Montgomery & Evans, 2009).
Whether children with SLI evidence a developmental
increase in STM capacity has been little studied. Gray (2004)
reported an increase in capacity between 3 and 6 years. How-
ever, capacity may level off by about 11 years, as suggested
by findings of a longitudinal study by Conti-Ramsden and
Durkin (2007). Their findings are inconsistent with the de-
velopmental literature showing that pSTM capacity does not
asymptote until about 14–15 years in TD children (Gathercole,
1999; Gathercole et al., 2004). Finally, there is evidence that
the STM deficit of children with SLI may be confined to the
verbal modality, as children with SLI and age peers tend to
perform similarly on visuospatial STM tasks (Alloway &
Archibald, 2008; Archibald & Gathercole, 2006, 2007).
Central Executive
It has only been recently that SLI researchers have begun
to study the central executive, primarily in the context of
WM tasks. Aspects of the executive that have been assessed
include attentional capacity and several attentional functions—
that is, allocation, inhibitory control, updating, and sustained
attention.
Attentional capacity. Attentional capacity refers to the
limited mental activation/energy available to a person to
perform a given task (Just & Carpenter, 1992). Most SLI
studies have tested attentional capacity using verbal tasks
(Ellis Weismer, Evans, & Hesketh, 1999; Mainela-Arnold &
Evans, 2005; Montgomery, 2000a), but some investigators
have also begun to include nonlinguistic tasks (Alloway
& Archibald, 2008; Archibald & Gathercole, 2006, 2007;
Windsor, Kohnert, Loxtercamp, & Kan, 2008). Irrespective
of the nature of the task, many children with SLI show re-
duced performance relative to age peers.
Ellis Weismer et al. (1999) compared the attentional
capacity of children with SLI and age peers. Using the
Competing Language Processing Task (CLPT; Gaulin &
Campbell, 1994), these investigators reported that both groups
yielded similar comprehension, but the SLI group yielded
significantly poorer word recall. Similar results have been
reported by others (Archibald & Gathercole, 2006, 2007;
Mainela-Arnold & Evans, 2005; Marton & Schwartz, 2003;
Montgomery, 2000a, 2000b; Montgomery & Evans, 2009).
Because all these studies show that children with SLI can
manage both comprehension and recall when the demands
for recall are light (i.e., few items need to be recalled), the
interpretation has been that children with SLI have reduced
attentional capacity compared to age peers. Archibald and
Gathercole (2006, 2007) and Windsor et al. (2008) have
extended these findings and interpretation to the nonlinguistic
domain. Im-Bolter, Johnson, and Pascual-Leone (2006) cor-
roborated the capacity limitation hypothesis using a variety
TABLE 1. Working memory (WM) and processing speed of
children with specific language impairment
(SLI) relative to age-matched peers.
WM/speed Relative to age peers
Short-term memory capacity
Verbal storage Poor
(Archibald & Gathercole, 2006, 2007; Ellis Weismer et al.,
2000; Gathercole &
Baddeley, 1990b; Montgomery, 1995, 2004)
Visuospatial storage Similar
(Alloway & Archibald, 2008; Archibald & Gathercole, 2006,
2007)
WM capacity
Concurrent processing stor-
age
Poor
(Archibald & Gathercole, 2006, 2007; Ellis Weismer et al.,
1999; Marton &
Schwartz, 2003; Montgomery, 2000a, 2000b; Montgomery &
Evans, 2009)
Central executive
Attentional capacity Poor
(Archibald & Gathercole, 2006, 2007; Ellis Weismer et al.,
1999;
Im-Bolter et al., 2006; Mainela-Arnold & Evans, 2005;
Montgomery & Evans, 2009)
Attentional allocation/shift-
ing
Similar
(Montgomery, 2000a, 2000b; Im-Bolter et al., 2006)
Updating Poor
(Im-Bolter et al., 2006)
Inhibition Poor
(Im-Bolter et al., 2006; Marton et al., 2007; Seiger-Gardner &
Schwartz, 2008)
Sustained attention Poor
(Finneran et al., 2009; Montgomery, 2008; Montgomery,
Polunenko,
& Marinellie, 2009; Spaulding et al., 2008)
Processing speed Poor
(Leonard et al., 2007; Miller et al., 2001; Windsor & Hwang,
1999; Windsor
et al., 2008)
Montgomery et al.: Working Memory and Language in SLI 81
of independent measures of attentional capacity. Collectively,
such findings and interpretation are consistent with the gen-
eral WM literature characterizing attentional capacity as a
domain-general cognitive attribute (Baddeley, 1996; Cowan,
1997; Cowan et al., 2005; Unsworth & Engle, 2007). Finally,
it is not clear whether children with SLI exhibit develop-
mental increase in attentional capacity, as there are no studies
directly addressing the issue.
Attentional control. Im-Bolter et al. (2006) evaluated three
attentional control functions in children with SLI. Using a
variety of independent tasks, they assessed shifting, updating,
and inhibitory control. Shifting, which is roughly analogous
to Baddeley’s (1996) resource allocation, is the ability to
devote attention between two different levels of a task (e.g.,
the processing and storage parts of a WM task) or to two
different tasks (Im-Bolter et al., 2006). Updating refers to
maintaining focus at a given level of a task and adding new
content to the focus of attention (e.g., adding to a list of to-be-
remembered items in storage in a WM task). Inhibition refers
to preventing irrelevant stimuli from entering WM or focus
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Running title Communication disorders 3NameUniversit.docx

  • 1. Running title: Communication disorders 3 Name: University: Professor: Date: Explain how understanding the conceptual model of working memory helps you in selecting strategies to take in helping a child that may have a communicative disorder. Please give an example of a strategy that you might use with a child with a specific communicative disorder. Construct a scenario of a team approach that could be developed when working with a child that has a specific communicative disorder. You should identify the communicative disorder that the child has in this scenario and provide research and techniques/strategies that are known to be effective with this type of communicative disorder. Evaluate the benefits for family and children in being connected to organizations associated with a specific
  • 2. communicative disorder. These organizations can be found from the list in your chapter reading or from an internet search. Explain how understanding the conceptual model of working memory helps you in selecting strategies to take in helping a child that may have a communicative disorder. Please give an example of a strategy that you might use with a child with a specific communicative disorder. Understanding the communication disorder is quite convenient towards the selection of the best mode of commiunication with a disabled child. (Sigman & Norman,1999). When am able to know some causes of communication disorders that the child is facing and this includes hearing loss in a child, neurological disorders, brain injury, mental retardation, drug abuse, physical impairments such as cleft lip or palate, emotional or psychiatric autism, and developmental disorders (Howlin, Mawhood, & Rutter, 2000), I will be able to freely interact with the child with the disorder without making him feel bad. This might include the use of include joint attention, imitation, and toy play to socialize with the autistic disorder. (Adamson & Bakeman,1985,1991) At 14 years, 8 months of age, Sam spontaneously imparted his aims, through nonverbal means, which included outward appearances (e.g., looking to staff to demand a nibble), physical motions (e.g., pulling his educators' hands to his head to demand a head rub), and more ordinary signals (e.g., indicating solicitation and a head shake to reject). He likewise utilized offbeat nonverbal flags that included gnawing his hand to impart positive and negative feelings and squeezing to dissent. Sam every so often utilized a couple of verbal word rough guesses (e.g., "no," "yes," "more," and "inflatable"), the sign for "help," and picture images on a voice yield gadget. Be that as it may, he commonly utilized these images latently, regularly
  • 3. because of a direct verbal brief from his social accomplice. From research, this shows that this is Autistic Disorder due to the fact that, he uses a variety of communication modes including speech, facial expressions, conventional gestures (e.g., pointing), unconventional signals (e.g., hand-flapping), vocalizations, picture symbols, and assistive technology (e.g., speech-generating devices) McCune, 1995; Ungerer & Sigman, 1984). There are several advantages that have been analysed in this article, just to state some, the connection of the family and disabled children or rather autistic persons is quite important due to the fact that they are able to connect and understand each other in their communication and thus makes it easy for the disabled one to fall in place and they are able to assist the child Kasari et al. (2004) References: Adamson, L., & Bakeman, R. (1985). Affect and attention: Infants observed with mothers and peers. Child Development, 56, 582–593. Adamson, L., & Bakeman, R. (1991). The development of shared attention during infancy. In R. Vasta (Ed.), Annals of child development (Vol. 8, pp. 1–41). London: Jessica Kingsley Publishers, Ltd Clift, S., Stagnitti, K., & Demello, L. (1988). A validation study of the test of pretend play using correlations and classifica- tional analyses. Child Language Teaching and Therapy, 14,199– 209. Dawson, G. (1991). A psychobiological perspective on the early socioemotional development of children with autism. In S. Toth, & D. Cicchetti (Eds.), Rochester symposium on developmental psychopathology (Vol. 3, pp. 207–234). Erlbaum: Mahwah, NJ
  • 4. O R I G I N A L P A P E R Early Predictors of Communication Development in Young Children with Autism Spectrum Disorder: Joint Attention, Imitation, and Toy Play Karen Toth Æ Jeffrey Munson Æ Andrew N. Meltzoff Æ Geraldine Dawson Published online: 15 July 2006 � Springer Science+Business Media, Inc. 2006 Abstract This study investigated the unique contribu- tions of joint attention, imitation, and toy play to language ability and rate of development of communication skills in young children with autism spectrum disorder (ASD). Sixty preschool-aged children with ASD were assessed using measures of joint attention, imitation, toy play, lan- guage, and communication ability. Two skills, initiating protodeclarative joint attention and immediate imitation, were most strongly associated with language ability at age 3–4 years, whereas toy play and deferred imitation were
  • 5. the best predictors of rate of communication development from age 4 to 6.5 years. The implications of these results for understanding the nature and course of language development in autism and for the development of targeted early interventions are discussed. Keywords Autism Æ Language Æ Communication Æ Joint attention Æ Imitation Æ Play Introduction It is well established that there is tremendous variability in outcome in autism. Long-term outcome studies have shown that while a majority of individuals exhibit poor to very poor outcomes, many individuals with autism go on to achieve adequate levels of academic, social, and occupa- tional functioning (Gillberg & Steffenburg, 1987; Lotter, 1978; Nordin & Gillberg, 1998; Sigman & Norman, 1999). In a recent study that followed children with autism from age 2 to 9, as many as 40% were found to have good outcomes based on language and cognitive scores (Stone,
  • 6. Turner, Pozdol, & Smoski, 2003). One of the strongest predictors of positive long-term outcomes for children with autism is the acquisition of spoken language (Bartak, Rutter, & Cox, 1975; Gillberg, 1991; Gillberg & Steffenburg, 1987; Lincoln, Courchesne, Kilman, Elmasian, & Allen, 1988; Lotter, 1978; Rutter, 1970). Early language ability (i.e., meaningful speech by 5–6 years of age) has been associated with both later academic achievement and social competence in individuals with autism (Howlin, Mawhood, & Rutter, 2000; Sigman & Ruskin, 1999; Venter, Lord, & Schopler, 1992). Given the critical importance of early language development for later prognosis, a better under- standing of developmental factors that underlie, facilitate, and predict language acquisition in autism would shed light on the nature of this disorder and allow for the refinement of targeted early interventions. Early abilities that have been associated with the development of language and communication skills both in
  • 7. typically developing children and children with autism include joint attention, imitation, and toy play. Joint attention—shared attention between social partners in relation to objects or events—typically emerges by 9–12 months of age (Adamson & Bakeman, 1985, 1991; Adamson & Chance, 1998; Brooks & Meltzoff, 2002; Bruner, 1983; Butterworth & Jarrett, 1991; Carpenter, Nagell, & Tomasello, 1998), with some aspects emerging as early as 6 months of age (Morales, Mundy, & Rojas, 1998). By 12 months of age, most typical infants display all aspects of joint attention, including sharing attention (e.g., through the use of alternating eye gaze), following the attention of another (e.g., following eye gaze or a K. Toth (&) Æ J. Munson Æ A. N. Meltzoff Æ G. Dawson Department of Psychology, UW Autism Center, CHDD, University of Washington, 357920, Seattle, WA 98195, USA e-mail: [email protected] J Autism Dev Disord (2006) 36:993–1005 DOI 10.1007/s10803-006-0137-7
  • 8. 123 point), and directing the attention of another (Carpenter et al., 1998). Through joint attention interactions, the infant begins to link words and sentences with objects and events (Baldwin, 1995). Importantly, it is within the context of joint attention episodes that infants also begin to commu- nicate intention by using sounds and gestures, such as reaching to request objects, and pointing and vocalizing to direct attention to objects. Joint attention skills correlate not only with early language learning, but also with later lan- guage ability in typically developing children (Carpenter et al., 1998; Meltzoff & Brooks, 2004; Morales et al., 1998, 2000; Mundy & Gomes, 1998). Children with autism, however, show impairments in joint attention skills as compared to children with delayed and typical development (Bacon, Fein, Morris, Water- house, & Allen, 1998; Charman, 1998; Charman et al.,
  • 9. 1998; Dawson, Meltzoff, Osterling, & Rinaldi, 1998; Dawson et al., 2002a, 2004; Mundy, Sigman, Ungerer, & Sherman, 1986; Sigman, Kasari, Kwon, & Yirmiya, 1992). Impairments in protodeclarative joint attention behav- iors—sharing attention for purely social purposes—appear to be more severe than impairments in protoimperative joint attention (e.g., requesting) behaviors in children with autism (Mundy et al., 1986; Mundy, Sigman, & Kasari, 1990; Sigman, Mundy, Sherman, & Ungerer, 1986). Fur- ther, in preschool age children with autism, joint attention is predictive of both current language ability, and future gains in expressive language skills (Bono, Daley, & Sigman, 2003; Charman et al., 2003; Dawson et al., 2004; Landry & Loveland, 1988; Mundy et al., 1990; Mundy, Sigman, Ungerer, & Sherman, 1987; Rogers & Hepburn, 2003; Sigman & Ruskin, 1999; Toth, Dawson, Munson, Estes, & Abbott, 2003). In a longitudinal study of social competence and language skills in children with autism and
  • 10. Down syndrome, Sigman and Ruskin (1999) found that protodeclarative joint attention skills were associated with early language ability for both groups, and predicted both short-term (i.e., 1 year later) and long-term (i.e., 8–9 years later) gains in expressive language ability for children with autism. Initiating protodeclarative joint attention in early childhood (3–6 years of age) was also correlated with later peer interactions (10–12 years of age). Further, protoim- perative joint attention skills correlated with early language ability and short-term, but not long-term, gains in expres- sive language for children with autism. In a recent inter- vention study that targeted joint attention skills, young children with autism showed greater gains in language 12 months post-treatment compared to controls (Kasari, Freeman, & Paparella, 2004). It may be that joint attention ability lays a foundation not only for the development of language, but also other complex abilities such as pretend play and theory of mind, as argued by developmental
  • 11. theorists (Bruner, 1983; Carpenter et al., 1998; Meltzoff, 2005; Meltzoff & Brooks, 2001) as well as in the literature more specifically focusing on children with autism (Charman, 1997, 2003; Mundy & Crowson, 1997; Sigman, 1997). Motor imitation ability has also been associated with the development of language and social communication skills. In typically developing infants, the ability to imitate is present at birth. Neonates are able to imitate simple facial movements, such as tongue protrusion and mouth opening (Meltzoff & Moore, 1977, 1997). By 9 months of age, infants are able to imitate actions on objects, both in immediate and deferred contexts (Carver, 1995; Meltzoff, 1988a). Infant imitation appears to serve several general functions, providing the child with shared social experi- ences, a sense of mutual connectedness, and a means of communication between social partners (Meltzoff, 2005; Trevarthen, Kokkinaki, & Fiamenghi, 1999). Through
  • 12. imitation, infants also learn about others’ actions and intentions (Meltzoff, 1999; Uzgiris, 1981, 1999). Deferred imitation serves to index infant recall memory and the child’s ability to produce actions based on stored mental representations of social events and action sequences (Klein & Meltzoff, 1999; Meltzoff, 1988b). It has been theorized that a failure to engage in early social imitative play may interfere with the development of joint attention, social reciprocity, and later theory of mind abilities (Dawson, 1991; Meltzoff, 1999, 2005; Meltzoff & Gopnik, 1993; Rogers & Pennington, 1991). Imitation not only plays an important role in early social development, but has also been shown to predict language ability in typically devel- oping children (Bates, Benigni, Bretherton, Camaioni, & Volterra, 1979). While typically developing children demonstrate the ability to imitate others from birth, children with autism demonstrate significant impairments in object imitation,
  • 13. imitation of facial and body movements, and deferred imitation of actions on objects (Charman, 1997; Dawson et al., 1998; Rogers, Bennetto, McEvoy, & Pennington, 1996; Rogers, Hepburn, Stackhouse, & Wehner, 2003; Sigman & Ungerer, 1984; Stone, Ousley, & Littleford, 1997). In children with autism, imitation skills have been found to correlate with early language ability (Dawson & Adams, 1984) and to predict later language ability (Charman et al., 2000, 2003; Stone et al., 1997; Stone & Yoder, 2001). In a recent study, immediate imitation of actions on objects at 20 months correlated with receptive language at 42 months in a small sample of children with autism (Charman et al., 2003). In a similar study, motor imitation at 24 months predicted expressive language ability at 48 months, even after controlling for initial language level, in young children with autism (Stone & Yoder, 2001). Play—both functional and symbolic—is a third skill domain that has been associated with language and social
  • 14. 994 J Autism Dev Disord (2006) 36:993–1005 123 communication ability. Play provides the child with opportunities for social interaction and social communi- cation, as well as a context for constructing representations of intentional states and knowledge (Bloom, 1993; Lifter & Bloom, 1989, 1998; Piaget, 1952). In typical development, functional, or pre-symbolic, play emerges during the first year, while symbolic play begins to emerge around 1 year of age and becomes increasingly complex over the second year of life. Both functional and symbolic play skills have been shown to correlate with language ability in typical children (Bates et al., 1979; McCune, 1995; Ungerer & Sigman, 1984). Symbolic play is correlated with both receptive and expressive language ability (Clift, Stagnitti, & Demello, 1988; Doswell, Lewis, Boucher, & Sylva, 1994; Lewis, Boucher, Lupton, & Watson, 2000), while
  • 15. functional play is correlated with expressive language level in preschool age children (Lewis et al., 2000). Longitudinal studies have also demonstrated a relation between early play skills and later language ability (McCune, 1995; Ungerer & Sigman, 1984). Ungerer and Sigman (1984) demonstrated that functional play at 13 months correlated with language ability at 22 months. Bates et al. (1979) found that both combinatorial (i.e., manipulative) and symbolic play correlated with gains in language from 9 to 13 months of age, with manipulative play predicting both receptive and expressive language abilities through the 9–13 month period, while symbolic play was related more to expressive language and was a stronger predictor toward the end of the 9–13 month period. McCune (1995) dem- onstrated that first word acquisition was associated with the emergence of symbolic play, both self-pretend (e.g., drinking from an empty cup) and other-pretend play (e.g., giving a stuffed animal a drink), and that combining
  • 16. actions in symbolic play (e.g., drinking from an empty cup, then giving a doll a drink) was associated with the onset of combining words. In contrast to typically developing children, children with autism show specific impairments in symbolic play as early as 18 months of age relative to children with delayed and typical development (Baron-Cohen et al., 1996; Charman et al., 1998; Dawson et al., 1998; Mundy et al., 1987; Ungerer & Sigman, 1981; Wing & Gould, 1979). When children with autism do acquire symbolic play skills, their level of symbolic play tends to remain below that of their language level (Amato, Barrow, & Domingo, 1999; Ungerer, 1989; Wing, 1978) and is often less diverse and elaborate compared to that of developmentally delayed and typical children (Ungerer & Sigman, 1981). Associations between play and language have also been demonstrated in young children with autism. Mundy et al. (1987) found that, at 3–6 years of age, receptive language ability cor-
  • 17. related with functional play involving a doll, and both expressive and receptive language skills correlated with symbolic play. Sigman and Ruskin (1999) demonstrated that, in 3–6-year-old children with autism, both functional and symbolic play in early childhood correlated with early language ability, and functional play correlated with long- term (i.e., 8–9 years later) gains in expressive language. A recent intervention study that targeted symbolic play skills found that young children with autism showed greater gains in language 12 months post-treatment compared to controls (Kasari et al., 2004). Although correlational and longitudinal research have demonstrated that joint attention, imitation, and play are associated with the development of language and com- munication skills in children with autism, the present study represents a unique contribution in two ways: First, the contributions of each of these three early abili- ties—joint attention, imitation, and toy play—were
  • 18. simultaneously examined as predictors of current lan- guage ability in a large sample of preschool age children with autism. Second, growth curve modeling was used to examine the relationship between these early skills and rate of development of communication skills across the preschool and early school age years in children with autism. Method Participants Sixty children with autism spectrum disorder (ASD), comprised of 42 children with Autistic Disorder and 18 children with Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS), participated in the study. Participants were recruited from local parent advocacy groups, public schools, clinics, hospitals, and the Washington State Division of Developmental Disabilities. Exclusionary criteria included the presence of a neurolog- ical disorder of known etiology, significant sensory or
  • 19. motor impairment, major physical abnormalities, and his- tory of serious head injury and/or neurological disease. Table 1 presents demographic and descriptive information, including gender, socioeconomic status, chronological age, composite mental age and IQ, and verbal age equivalents for the children who participated in the study. At the beginning of the study, children ranged in age from 34 to 52 months and were followed until 65 to 78 months of age. Ethnicity for the sample was as follows: 43 European- American, 3 African-American, 11 Multi-racial, and 3 Asian/Pacific Islander. Twelve children (20%) displayed an expressive language age equivalence of 36 months or higher on the Mullen Scales of Early Learning. Based on the ADI-R, 20 children were reported to have lost some level of spontaneous, meaningful communicative speech. J Autism Dev Disord (2006) 36:993–1005 995 123
  • 20. Eighty-two percent of mothers had some college or a col- lege degree. Diagnosis of autism was based on the Autism Diag- nostic Interview—Revised (ADI-R; LeCouteur, Lord, & Rutter, 2003; Lord, Rutter, & LeCouteur, 1994) and the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 2000; Lord, Rutter, DiLavore, & Risi, 1999; Lord, Rutter, Goode, & Heemsbergen, 1989). Both instruments assess the symptoms of Autistic Disorder listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV; American Psychiatric Association, 1994). In addition, clinicians made a clinical judgment of diagnosis based on presence/absence of autism spectrum symptoms as defined in the DSM-IV. Diagnosis of autism was defined as meeting criteria for autism on the ADOS and autism spectrum on the ADI-R and meeting DSM-IV criteria for Autistic Disorder based on clinical judgment. In addition, if a child received a diagnosis of autism on the ADOS and
  • 21. based on DSM-IV clinical diagnosis, and came within 2 points of meeting autism spectrum criteria on the ADI-R, the child was also considered to have autism. Diagnosis of PDD-NOS was defined as meeting criteria for autism spectrum on the ADOS and on the ADI-R, or missing criteria on the ADI-R by 2 or fewer points, and meeting DSM-IV criteria for PDD-NOS based on clinical judgment. Procedure The following measures were gathered over the course of three or more sessions when children were 3–4 years old. Each child was individually tested while seated at a table. The child’s parent remained in the room, seated behind the child or at the table with the child on the parent’s lap. Children were given food snacks and praise as reward for sitting at the table when necessary and provided breaks as needed. The ADOS, ADI-R, and Mullen Scales of Early Learning: AGS Edition (Mullen, 1997) were administered during the child’s first laboratory visit, the Early Social
  • 22. Communication Scales (ESCS) was administered during the second visit, and experimental assessments of imitation and functional and symbolic toy play were administered during subsequent visits. The Vineland Adaptive Behavior Scales: Survey Form (Sparrow, Balla, & Cicchetti, 1984) was administered to the parent(s) in person when the child was 3–4 years of age, and every 6 months thereafter by phone up to 6 years, 6 months of age. Predictor Variables The Early Social Communication Scales (ESCS; Mundy, Delgado, Hogan, & Doehring, 2003; Seibert & Hogan, 1982) was used to measure both protodeclarative and protoimperative joint attention behaviors. In this proce- dure, the child was seated at a table across from a familiar examiner. A set of toys including a hat, comb, pair of glasses, book, ball, car, wind-up and hand-operated toys, and a plastic jar was in view, but out of reach of the child. Three wall posters hung 90 degrees to the child’s right and
  • 23. left, and 180 degrees behind the child. The examiner pre- sented a sequence of wind-up and hand-operated toys, activating each three times per trial (6 trials). Intermit- tently, the examiner attracted the child’s attention, then turned to point and gaze at each poster while calling the child’s name three times (2 trials of 3 probes each), made simple gestural and verbal requests of the child (‘‘Give it to me’’), and presented the child with turn-taking opportuni- ties, consisting of a tickle game (2 trials), taking turns with an object (2 trials), and taking turns wearing a hat, comb, and glasses (3 trials). The examiner also gave the child the opportunity to look at pictures in a book and follow the examiner’s point (1 trial). This 20-min structured assess- ment was videotaped from behind a one-way mirror to include a full view of the child and a profile view of the examiner. Behavioral ratings were made from the video- tapes by trained observers blind with respect to diagnosis (these same observers also coded tapes of children with
  • 24. delayed and typical development as part of a larger study) and hypotheses. A more complete discussion of the ESCS procedure is available elsewhere (Mundy et al., 2003). Initiating and Responding to Protodeclarative Joint Attention Behavioral observations from the 20-min ESCS procedure yielded scores in two categories of protodeclarative joint attention. Initiating Protodeclarative Joint Attention could Table 1 Sample characteristics a N M:F SES+ CA (mos) Mullen Composite MA (mos) Mullen Composite IQ Mullen Verbal AE (mos) b 60 51:9 46.2 43.6 25.4 58.1 22.9 SD (11.2) (4.3) (8.6) (19.8) (10.3) Range 22–66 34–52 11.8–46.8 30–101 8–50 a Numbers in the first row represent means; second row, standard deviations (SDs) in parentheses; third row, range b The Mullen verbal age equivalent is the average of the Mullen receptive language and Mullen expressive language age
  • 25. equivalents 996 J Autism Dev Disord (2006) 36:993–1005 123 occur at any time during the assessment and consisted of the number of times the child used eye gaze, alternating eye gaze, showing, and/or pointing behaviors to direct and/ or share attention with the examiner with respect to an active toy. Responding to Protodeclarative Joint Attention was the percentage of six trials on which the child accu- rately oriented with eyes and/or head turn beyond the examiner’s finger and in the direction of the examiner’s point and gaze to the posters. Initiating Protoimperative Joint Attention A frequency score was obtained for Initiating Protoim- perative Joint Attention based on observations from the ESCS, which could occur at any time during the assess- ment and consisted of the number of times the child used
  • 26. eye gaze, reaching with coordinated eye gaze, pointing, and/or giving to request a toy or to request help. Dyadic behaviors (e.g., a reach without coordinated eye contact) were not included in this category. Reliability of the behavioral coding of the ESCS task occurred in two phases. First, initial reliability was assessed by independent paired ratings using 15 taped ESCS sessions provided by Peter Mundy. Each of five raters (undergraduate research assistants) independently coded the 15 tapes and these ratings were then compared to those obtained by Peter Mundy using intra-class correlation coefficients. The coefficients for the three variables used in the present study—initiating and responding to protode- clarative joint attention and initiating protoimperative joint attention—ranged from .83 to .94. After achieving this initial reliability, the five raters then began coding data for the study using a detailed coding manual developed by the first author based on conversations with Mundy and staff
  • 27. that occurred during the process of obtaining initial reli- ability. A second phase of reliability was assessed using independent paired ratings made from videotapes for a randomly selected group of participants (10% of total sample). Intra-class correlation coefficients for this second phase of reliability were .80 for initiating protodeclarative joint attention, .75 for responding to protodeclarative joint attention, and .86 for initiating protoimperative joint attention. Imitation and Deferred Imitation Immediate and deferred motor imitation abilities were assessed based on a battery developed by Meltzoff (1988a, b) and previously used with children with autism (Dawson et al., 1998) and Down syndrome (Rast & Meltzoff, 1995). The battery consisted of 10 motor imitation items admin- istered in 2 blocks, 5 immediate and 5 deferred. Items involved simple actions on novel objects, such as pressing a light panel with one’s forehead, hitting two red blocks
  • 28. together, and inverting and collapsing a camping cup. Block order was counterbalanced and order of presentation of specific items within each block was randomly deter- mined. The child was seated at a table across from a familiar examiner. After gaining the child’s attention, the examiner demonstrated each target action 3 times in about 20 s. In the immediate condition, after demonstrating all 5 actions, the examiner then handed the object(s) to the child one at a time and said, ‘‘It’s your turn.’’ No other verbal or physical prompts were used to elicit a response. In the deferred condition, after demonstrating all 5 actions, a 10-min delay was introduced during which the child was escorted out of the test room. After the delay, the child returned to the test room and the examiner handed the object(s) to the child one at a time and said, ‘‘Here’s a toy for you to play with.’’ In both conditions, the child’s behavior was coded during a test period of 20 seconds, which began from the time the child first touched the
  • 29. object(s). Behavioral ratings were made live by a trained clinician and from an immediate review of the videotapes when a judgment could not be made live (this occurred infrequently). The same clinician administered this mea- sure to all children in the study. The dependent measure was the total number of acts imitated, ranging from 0 to 5 for each condition. Intra- and inter-observer agreement were both high. Intra-observer agreement was assessed by having the initial coder rescore a randomly selected 10% of the children from videotape. The coder waited more than 4 months after the first coding and was uninformed as to the initial scoring. For the inter-observer assessment, a second independent coder reviewed the videotapes of the same randomly selected children, while remaining unin- formed as to the initial scoring. There were few disagree- ments: Intra- and inter-observer agreement, as assessed by Pearson rs, were respectively .99 and .99 for immediate imitation and 1.00 and .96 for deferred imitation.
  • 30. Toy Play In this structured assessment of functional and symbolic toy play skills, the child was seated at a table across from a familiar examiner. Six dolls and sets of stimuli, func- tional and representational, were presented to the child one at a time, with functional and symbolic conditions (3 dolls and sets of stimuli per condition) counterbalanced across participants. Representational stimuli included a block to represent a sandwich, a plastic lid and bag to represent a blanket and pillow, a tongue depressor to represent a comb, a small plastic object to represent a cup, a shoebox to represent a bathtub, and a blue wooden J Autism Dev Disord (2006) 36:993–1005 997 123 cylinder to represent a toothbrush. Functional objects for each of these (e.g., a plastic sandwich, a comb, etc.) were also included. For each condition, the child was presented
  • 31. with a doll and object(s) and told, ‘‘You can play with these.’’ Every 20 seconds, if the child was playing with only some of the toys or not at all, the examiner repeated the statement, ‘‘You can play with all of these’’ and gestured to all of the toys. No further verbal or physical prompts were provided. After 1 min, the toys were removed from the table and the next doll and object(s) were presented. The dolls were first presented unprompted for each condition. For any target actions not performed by the child, prompted trials were then given. Prompted trials consisted of a verbal and gestural prompt, such as ‘‘Wally is hungry, give him a sandwich’’ while the examiner patted her own stomach, but the examiner did not model the target action on the doll. The child’s re- sponses were scored in the following way: target action was performed on the doll, on self, or on another person (both prompted and unprompted trials were credited a score of ‘1’ if the target action was performed); another
  • 32. symbolic action was performed to self or other (these actions were not included in the score); target action was not performed (score of ‘0’). Functional and symbolic play were highly correlated in this sample (r = .68) and were therefore summed together to create one total play score ranging from 0 to 6 (score of 0–3 possible for functional play acts and 0–3 for symbolic play acts). The same clinician administered this measure to all children in the study. Behavioral ratings were made live by a trained clinician (and in a few instances of ambiguity from immediate review of the videotapes). Intra-observer agreement was assessed by having the initial coder re- score a randomly selected 10% of the children from videotape (more than 4 months after the first coding, while remaining uninformed as to the first judgments). For the inter-observer assessment, a second independent coder reviewed the same videotapes while uninformed as to the initial scoring. Intra- and inter-observer agreement
  • 33. for the total play score were, respectively, r = .97and .96. Language Measures Mullen Scales of Early Learning: AGS Edition Receptive and expressive language age equivalents and standard scores were derived from subscales of the Mullen Scales of Early Learning (Mullen, 1997), which is a stan- dardized measure of cognitive function for infants and preschool age children. The Mullen was administered to each child at age 3–4 years to obtain a measure of overall cognitive ability as well as separate scores for both receptive and expressive language abilities. Vineland Adaptive Behavior Scales: Survey Form The Vineland Adaptive Behavior Scales (Sparrow et al., 1984) is a standardized parent interview that includes assessment of communication skills (i.e., receptive, expressive, and written communication). The Vineland was administered by phone every 6 months from age 3–4 to 6.5 years. Although the Vineland norms were based on in-
  • 34. person administration of the instrument, the decision was made to administer the Vineland by phone for this sample in order to lessen the burden on parents. Interviewers were blind to the Vineland responses obtained previously, and each time the Vineland was administered, a new basal and ceiling were obtained. In addition, the same parent was interviewed at each time point. Interviewers followed the procedure as outlined in the Vineland manual, beginning with a broad interview format followed by more targeted questions to gather the information necessary to score each item. The overall communication subscale age equivalent score every 6 months up to 6.5 years of age was used in growth curve analyses, with an average of 6 data points per child. Age equivalent scores were chosen over raw scores as they provide a more meaningful metric with which to interpret change over time (i.e., increase in months rather than Vineland points). Communication ability as assessed by the Vineland was highly correlated with language
  • 35. ability as assessed by standardized language tests, both at the outset of the study and at final follow-up at age 6 years. This suggests that, for this sample, Vineland communica- tion scores were a reasonably good measure of receptive and expressive language ability. At age 3–4 years, the Mullen verbal age equivalent and the Vineland communi- cation age equivalent were correlated .78 (Vineland and Mullen receptive language age equivalents were correlated .48, and Vineland and Mullen expressive language age equivalents were correlated .81). At age 6 years, the Vineland communication standard score and the verbal standard score as measured by the Differential Ability Scales (DAS) were correlated .72. Results Means, standard deviations (SD), and ranges for the pre- dictor variables are presented in Table 2. Correlations among predictor variables were moderate, ranging from .20 to .67 (Table 3). The various language variables used in the
  • 36. regression analyses were highly correlated with each other (r = .89–.97 among Mullen variables, and .71–.79 between Mullen and Vineland variables). Correlations between predictor variables and initial language ability are shown in Table 4. To determine the unique contributions of each of the predictor variables to concurrent language, multiple 998 J Autism Dev Disord (2006) 36:993–1005 123 regression analyses were conducted. Although predictors were moderately correlated with one another, multicollin- earity diagnostics indicated adequate tolerance levels. Contributions of Joint Attention, Imitation, and Toy Play to Language Ability at Age 3–4 years Multiple regression analyses were conducted with all of the predictor variables entered in one step, in which case the test of the partial regressions weight controls for all the other predictors in the model. Results are presented in
  • 37. Table 5 and indicate that across a range of language variables—receptive and expressive language, parent report and direct observation—initiating protodeclarative joint attention and immediate imitation were most strongly associated with concurrent language ability in 3–4-year-old children with autism. Predicting Rate of Communication Development Next, to examine the degree to which these three early abilities—joint attention, imitation, and toy play— accounted for the variability in rate of communication development over the preschool and early school age per- iod, growth trajectories using repeated Vineland measure- ments were modeled using Hierarchical Linear Modeling (HLM; Raudenbush & Bryk, 2002) with two parameters, an intercept (absolute communication level at 48 months) and a linear slope. 1 Time was thus coded in months and centered around 48. The six individual predictor variables
  • 38. were standardized and entered as predictors of individual differences in the growth trajectories (both intercepts and slopes). As shown in Table 6, immediate imitation and toy play abilities were significantly related to individual dif- ferences in children’s communication ability at 48 months as measured with the Vineland, partially replicating results examining predictors of early language using the Mullen language scores reported above. (Note that the correlations with the Mullen Language Scores were computed at entry into the study when children were slightly younger, 3–4 years of age). The coefficients at the intercept indicate that children whose immediate imitation ability was 1 SD above the mean had communication scores over 3 months higher than those at the sample mean, and children with toy play ability 1 SD above the mean had communication scores 3 months higher than those at the sample mean. Examining individual differences in the slope (rate of change), it was found that both toy play and deferred
  • 39. imitation were significantly and positively related to rate of acquisition of communication skills over the next 2 years (see Fig. 1). The average rate of change for the sample was .75, meaning that the sample as a whole showed 3 4 of a month’s growth in communication ability for each chro- nological month that passed. Two skills, toy play and deferred imitation, were related to rate of change. Children who had toy play scores 1 SD above the sample mean (while controlling for all other variables) showed a rate of change of .91 month/chronological month (or 11 months for every year), whereas children with toy play scores 1 SD below the sample mean had a rate of change of only .59 month/chronological month (7 months for every year). Similarly, children with deferred imitation scores 1 SD above the sample mean showed a rate of change of .96 month/chronological month (11.5 months per year),
  • 40. whereas children with deferred imitation scores 1 SD below the sample mean had a rate of change of only .54 month/chronological month (6.5 months per year). Inasmuch as both these variables—toy play and deferred imitation—predicted unique variability in the rate of change, their additive effect was even greater. Thus, the combination of better toy play ability and more developed deferred imitation skills was associated with faster rates of change in communication skills across the preschool and early school age period. These positive associations Table 2 Descriptive statistics for predictor variables Predictor M (SD) Range Init Protodecl JA a 7.9 (8.7) 0–43 Resp Protodecl JA (%) b .51 (.35) 0–1 (%) Init Protoimp JA c
  • 41. 11.2 (8.8) 0–36 Imitation-Immediate d 2.9 (1.7) 0–5 Imitation-Deferred e 1.9 (1.6) 0–5 Toy Play f 4.0 (2.2) 0–6 a Initiating protodeclarative joint attention was a frequency score consisting of the number of times the child used eye gaze, alternating eye gaze, showing, and/or pointing behaviors to direct and/or share attention with the examiner with respect to an active toy b Responding to protodeclarative joint attention was the percentage of six trials on which the child accurately oriented with eyes and/or head turn beyond the examiner’s finger and in the direction of the
  • 42. exam- iner’s point and gaze to the posters c Initiating protoimperative joint attention was a frequency score consisting of the number of times the child used eye gaze, reached with coordinated eye gaze, gave objects, and/or pointed to request a toy or to request help d Immediate imitation consisted of the total number of immediate imitation items imitated e Deferred imitation consisted of the total number of deferred imitation items imitated f Toy play consisted of the number of functional and symbolic play acts performed, prompted or unprompted 1 An unconditional model with both linear and quadratic terms was also run. The quadratic term in this model was not significantly dif- ferent from zero (coeff. = .001134, std error = .0031, t(59) =
  • 43. .365, P = .716) and showed much less variability than the linear term (variance component: linear term = .34247, quadratic term = .00025), thus the model with the single linear slope was deemed most appropriate for these data. J Autism Dev Disord (2006) 36:993–1005 999 123 remained for deferred imitation (t = 2.07, P < .05) and nearly so for toy play (t = 1.81, P = .076) even after controlling for child IQ. Discussion One purpose of the present study was to better understand the contributions of each of three early abilities—joint attention, imitation, and toy play—to early language ability in young children with autism. Previous studies have pri- marily demonstrated correlations between each of these skill domains, and early and later language ability in
  • 44. children with autism. In the present study, when these three abilities were examined simultaneously, initiating protodeclarative joint attention and immediate imitation abilities were most strongly associated with language skills in 3–4-year-old children with autism. Table 6 HLM growth curve analyses predicting rate of acquisition of communicative skills in young children with autism Intercept is Vineland communication score at 48 months; *P < .05, **P < .01 Intercept (48 mos.) Slope (Rate of change) Coeff t Coeff t Constant 22.61 27.95** .75 14.34** Joint attention—protodeclarative
  • 45. Initiate 1.10 1.20 –.06 –1.27 Respond 1.30 1.10 .03 .38 Joint attention—protoimperative Initiate –1.28 –1.29 –.01 –.11 Imitation objects Immediate 3.20 3.47** –.01 –.80 Deferred 2.08 1.61 .21* 2.61* Toy Play 3.02 2.54* .16* 2.34* Table 3 Correlations among predictor variables: joint attention, imitation, and toy play Init Protodecl JA Resp Protodecl JA Init Protoimp JA Symbolic Play Imitation immediate Imitation deferred Functional Play .31* .51*** .23 .67*** .43** .41** Init Protodecl JA .43** .39** .48*** .28* .45*** Resp Protodecl JA .38** .58*** .44*** .66*** Init Protoimp JA .24 .20 .20 Symbolic Play .37** .50*** Imitation-Immediate .53*** *P < .05, **P < .01, ***P < .001
  • 46. Table 4 Relations between joint attention, imitation, and toy play, and language ability Init Protodecl JA Resp Protodecl JA Init Protoimp JA Toy Play Immediate imitation Deferred imitation Mullen Verbal AE .53** .60** .23 .54** .66** .67** Mullen Rec Lang AE .49** .58** .20 .50** .64** .66** Mullen Expr Lang AE .53** .59** .25 a .56** .64** .63** Vineland Comm AE .53** .62** .30* .51** .56** .65** *P < .05, **P < .001 a P = .05 Table 5 Relations between joint attention, imitation, and toy play, and current language ability in 3–4-year-old children with autism Mullen Verbal AE Mullen Rec Lang AE Mullen Expr Lang AE Vineland Comm AE Init Protodecl JA .25* .23* .25* .25* Resp Protodecl JA .16 .16 .15 .23 Init Protoimp JA –.06 –.08 –.04 .02 Toy play .08 .03 .12 –.02
  • 47. Imitation immediate .39*** .38** .37** .26* Imitation deferred .22 .26* .17 .26 Total R 2 .65 .62 .62 .58 Numbers are standardized betas; *P < .05, **P < .01, ***P < .001 1000 J Autism Dev Disord (2006) 36:993–1005 123 A second aim of this study was to better understand the relationship between these early skills and rate of acqui- sition of communication skills during the preschool and early school age years in children with autism. Using growth curve modeling, it was found that toy play and deferred imitation were associated with higher rates of acquisition of communication skills between 4 and 6.5 years of age. That is, children with autism who had better toy play and deferred imitation abilities at age 4
  • 48. acquired communication skills at a faster rate than those with less developed toy play and deferred imitation skills. For example, children who performed 1 SD above the sample mean in both toy play and deferred imitation skills had communication acquisition rates that were comparable to typical children (13.4 months of communication growth per 1 year of chronological age). (However, because the children with autism started out at a lower level, their language skills were still below age level at outcome.) In comparison, children who performed 1 SD below the mean in both toy play and deferred imitation skills acquired communication skills at a rate of only 4.5 months per 1 year of chronological age. These findings have important implications for under- standing the nature and course of language development in autism, and for designing targeted early interventions. While initiating protodeclarative joint attention and immediate imitation contributed to language ability at the
  • 49. outset, toy play and deferred imitation were predictive of rate of development of communication skills over the next few years. These findings suggest that while all three abilities might be important for laying a foundation for language development in autism, toy play and deferred imitation skills might contribute to the continued expansion of language and communication skills over the preschool and early school age period. This is not to suggest that joint attention is not related to later language ability in autism. Children with stronger joint attention skills also began with better language at 3–4 years of age. That is, our findings showed that children with better-developed initial joint attention skills also had better-developed initial language ability, and these children continued to show higher lan- guage and communication skills across the preschool and early school age years. Overall, however, when joint attention was examined together with imitation and toy play, only deferred imitation and toy play remained sig-
  • 50. nificantly associated with rate (i.e., slope) of change in communication skills over time. We can speculate that joint attention and immediate imitation are important ‘‘starter set’’ skills that set the stage for social and communicative exchanges in which language can develop, as described in the introduction. Once this stage is set and the child begins to learn to use language in a communicative manner, representational skills become important in the continued acquisition of words and phrases during the preschool and early school age period. Toy play and deferred imitation abilities often involve shared attention, but they also index higher level cognitive skills that are important for the continued development and expansion of language and social com- munication abilities: an active interest, curiosity in, and exploration of the environment; representational thought, memory; and cognitive planning. While joint attention episodes occur in a social context, both toy play (particu-
  • 51. larly as it was measured here with dolls) and deferred imitation require that the child actively attend to the immediate environment, observe the events and actions taking place, then reproduce these events and socially- mediated actions at a later time. The ability to demonstrate these skills requires an active interest in people and/or things (capturing the child’s attention), representational thinking (forming and storing a mental representation), intact recall memory (calling up that representation at a later time), and both cognitive and motor planning skills in order to reproduce the action or event (Klein & Meltzoff, 1999; Meltzoff, 1988b, 1999). Additionally, the child’s ability to reproduce actions at a later time reflects not only symbolic thinking and intact recall memory, but also a ‘‘shared attitude toward objects,’’ as the child demonstrates the same actions on objects that he has witnessed of others (Meltzoff, 2005; Meltzoff & Gopnik, 1993). Thus, through toy play and imitation, the child not only comes to an
  • 52. understanding of the world around him—what people do and think and how objects work—but also has the oppor- tunity to demonstrate that understanding. The results of the present study also have implications for early intervention. All three skill domains—joint attention, imitation, and toy play—are related to the development of language and communication abilities in young children with autism and are therefore important Child's Age in Months 45 50 55 60 65 70 75 80 V in e la n d C o m m u
  • 54. 70 Mea n tra jecto ry Toy Pla y, D efe rred Imi tati on +1 SD Toy Play , Deferre d Imitatio n -1 SD Nor mat ive gro
  • 55. wth Fig. 1 Comparison of rates of acquisition of communication skills in children with autism who have toy play and imitation skills either 1 SD above, or 1 SD below, the sample mean J Autism Dev Disord (2006) 36:993–1005 1001 123 targets for early intervention. A number of studies have shown promising results in facilitating the development of joint attention in children with autism (Klinger & Dawson, 1992; Siller & Sigman, 2002; Whalen & Schreibman, 2003). Kasari et al. (2004) recently conducted a treatment study that examined two interventions, one that targeted joint attention skills and one that targeted play skills. The play intervention focused not only on symbolic acts, but also overall level of play. Children with autism were ran- domly assigned to one of three groups—the joint attention treatment group, the play treatment group, or the control
  • 56. group—upon admission to the program. The control group participated in a general early intervention program. Results showed that children in the joint attention inter- vention group showed significantly more pointing and showing, more responses to joint attention, and more child- initiated joint attention in mother–child interactions than at pre-treatment. Similarly, children in the play group showed significantly greater frequencies and types of play acts and higher play levels on both a structured play assessment and during mother–child interactions than at pre-treatment. Further, over a 14-month period, the two experimental groups showed an average of 15–17 months gain in expressive language ability compared to only 7.5 months for the control group. Although this study did not examine pre-treatment differences among groups on a range of variables, the results demonstrate that skills such as joint attention and play may be modified and may contribute to gains in other skill areas, such as expressive language
  • 57. ability, in children with autism. Another treatment study examined the behavioral pro- files of responders and non-responders to Pivotal Response Training (PRT) (Sherer & Schreibman, 2004 in press). Children with responder profiles tended to have better- developed toy play skills at pre-treatment, demonstrated greater gains in language, play, and social skills during treatment sessions than non-responders, and also general- ized these skills to no-treatment environments and untrained stimuli. Although the study design used in the Sherer and Schreibman study precludes conclusions as to whether improvement occurred in response to treatment or in response to treatment plus other factors, it does tell us that certain skills, such as toy play skills, might influence the acquisition of language and other abilities that are targeted in the treatment of children with autism. It should be noted that due to the wide heterogeneity in language skills in autism, meaningful speech, that is,
  • 58. speech that is frequent or consistent, referential, and communicative, is difficult to assess with any one measure. Standardized cognitive tests sample behavior over the course of 1 h, while parent report measures such as the Vineland provide a summary of behavior over a broader time frame and range of settings. Each of these measures captures some, but not all, aspects of meaningful commu- nication. In the current study, the Vineland was shown to be highly correlated with direct assessment of language in this sample, and was therefore deemed a suitable measure of rate of language acquisition over time in young children with autism. The Vineland also allowed for a repeated measure appropriate for growth curve analysis that was not confounded by test practice effects. The broader issue of what measure best captures meaningful or useful speech remains an important one, but one that lies outside the scope of this study. In summary, the results of the present study shed light
  • 59. on the relationship between early skill domains and the development of language and communication in young children with autism, and suggest specific targets for early intervention. Early abilities involved in social exchange and communication, namely, joint attention and immediate imitation, appear to be important for setting the stage for early language learning in autism, while representational skills, demonstrated through toy play and deferred imita- tion, contribute to the continued expansion of language and communication skills over the preschool and early school age years. Each of these skill areas represents an important target for early intervention programs that promote com- municative competence and improved outcomes for young children with autism. Acknowledgments This research was funded by a program project grant from the National Institute of Child Health and Human Development and the National Institute on Deafness and Communi-
  • 60. cation Disability (U19HD35465), which is part of the NICHD/NID- CD Collaborative Program of Excellence in Autism and by a center grant from the National Institute of Mental Health (U54MH066399), which is part of the NIH Studies to Advance Autism Research and Treatment (STAART) Centers Program. We gratefully acknowledge the contributions of the parents and their children who participated in this study and several other people who made significant contributions to this research: Craig Harris and several undergraduate research assistants. References Adamson, L., & Bakeman, R. (1985). Affect and attention: Infants observed with mothers and peers. Child Development, 56, 582– 593. Adamson, L., & Bakeman, R. (1991). The development of
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  • 84. Mianisha C. Finney Ohio University, Athens Purpose: Children with specific language im- pairment (SLI) demonstrate significant language impairments despite normal-range hearing and nonverbal IQ. Many of these children also show marked deficits in working memory (WM) abilities. However, the theoretical and clinical character- ization of the association between WM and language limitations in SLI is still sparse. Our understanding of this association would benefit greatly from an updated and thorough review of the literature. Method: We review the newest developments in these areas from both a theoretical and clinical perspective. Our intent is to provide researchers and practicing clinicians (a) a conceptual frame- work within which the association between WM and language limitations of children with SLI can be understood and (b) potentially helpful suggestions for assessing and treating the memory-language difficulties of children with SLI. Conclusions: In the past 10 years, important new theoretical insights into the range and nature of WM deficits and relation between these limitations and the language difficulties in SLI have occurred. New, robust diagnostic assess- ment tools and computerized treatment methods designed to enhance children’s WM functioning have also been developed. The assessment, diagnosis, and treatment of the language diffi- culties in SLI should consider the potential influence of WM.
  • 85. Key Words: children, specific language impairment, working memory, language M any children with specific language impairment (SLI) exhibit significant working memory (WM) deficits relative to same-age peers. In 2002, Montgomery published a review article on what was known about the WM deficits of children with SLI and the relation of these deficits to these children’s language problems. Since then, new and important insights into WM and language in children with SLI and typically developing (TD) children have occurred. We review these new developments. We cast the WM deficits and their relation to SLI in broad theoretical terms, which allows us to contextualize the WM issues defining the current SLI literature. During this same period, new WM assessment tools and computerized training meth- ods designed to remediate the WM deficiencies of children have been developed. Many of these tools are available to the practicing speech-language pathologist (SLP). These new developments and their clinical relevance to SLI will be reviewed. Children with SLI demonstrate normal-range hearing and nonverbal intelligence and an absence of developmental disability (e.g., autism or fragile X syndrome) yet marked expressive and/or receptive language difficulties for their age. Many children with SLI also exhibit limitations in WM. WM refers to the mental processes allowing limited infor- mation to be held in a temporary accessible state during cognitive processing (Cowan, Nugent, Elliott, Ponomarev, & Saults, 2005); that is, WM involves concurrent informa- tion processing and storage. Because WM is considered a primitive of higher level cognition (e.g., Unsworth & Engle,
  • 86. 2007), including fluid intelligence, language learning/ performance, and academic learning, it is important to un- derstand its nature. The WM system includes various mech- anisms and properties. Over the past decade, the range of WM problems exhibited by children with SLI has broadened, and the evidence implicating an association between the WM and language difficulties in children with SLI has grown. This said, it should be noted that children with SLI repre- sent a heterogeneous population not only with respect to the linguistic deficits they exhibit (Leonard, 1998) but also as to whether they demonstrate WM limitations. Although WM Tutorial American Journal of Speech-Language Pathology • Vol. 19 • 78–94 • February 2010 • A American Speech-Language-Hearing Association78 limitations characterize many children with SLI, not all chil- dren with SLI evidence such deficits (Archibald & Joanisse, 2009). The information in the present article reflects what is known about children with SLI who do demonstrate WM problems. WM in TD Children A Theoretical Backdrop To better understand the SLI literature, it is important to have some familiarity with the key issues defining the re- cent developmental memory literature. The majority of WM research has been conducted within Baddeley’s original tripartite framework (Baddeley & Hitch, 1974). This model describes WM as a multidimensional system comprising three separable yet interactive mechanisms (Bayliss, Jarrold,
  • 87. Baddeley, Gunn, & Leigh, 2005; Gathercole, 1999; Gavens & Barrouillet, 2004; Towse, Hitch, & Hutton, 1998). One is a domain-general central executive responsible for coordi- nating and controlling the different activities within WM. The executive has finite attentional resources (mental energy/ capacity) that are controlled in a flexible manner. Attentional control is key, and its regulatory functions include such things as allocation (the ability to devote mental energy to different levels of a task), updating (changing the contents of WM through attention switching), sustained attention (the ability to attend selectively to a stimulus in the midst of interference), and inhibition (the ability to block irrelevant stimuli from WM or focus of attention; Baddeley, 1996; Barkley, 1996; Lehto, Juujarvi, Kooistra, & Pulkkinen, 2003). The executive is roughly similar to the view of WM espoused by Cowan (Cowan, 1997; Cowan et al., 2005) as the acti- vation of a subset of representations (e.g., words) stored in long-term memory that momentarily occupy the focus of attention, and by Engle (Engle & Kane, 2004; Unsworth & Engle, 2007) as attentional capacity and control. The second and third mechanisms correspond to two domain-specific storage devices, one devoted to the tempo- rary retention of verbal material, the phonological loop, and the other to visuospatial input, the visuospatial sketchpad. In this article, we focus on the loop, hereafter referred to as phonological short-term memory (pSTM). Recently, Baddeley (2000, 2003) proposed a fourth mechanism, the episodic buffer. The buffer is assumed to function as a temporary storage device and a processing system capable of integrating inputs from pSTM and the visuospatial sketchpad into a coherent episode/representation. It is thought to be important to the processing and retention of large chunks of language material such as connected speech. Because the buffer is a newly proposed mechanism, it does not enjoy the same theo- retical specificity and empirical validation as the other com-
  • 88. ponents (Baddeley, 2003). Finally, though not a mechanism, developmental memory researchers have begun to examine processing speed as an important property of WM and a potential factor in defining the capacity limits of WM (Bayliss et al., 2005; Towse & Hitch, 1995; Towse et al., 1998). In- terest in speed derives from earlier work revealing reliable intercorrelations among processing speed, short-term mem- ory (STM), chronological age, and higher level cognitive abilities (Fry & Hale, 1996, 2000; Gathercole & Baddeley, 1993; Kail, 1991). We are interested in processing speed because of its emerging association with WM and central focus in the SLI literature. The basic architecture of the tripartite model—that is, central executive, pSTM, and visuospatial STM—seems to be developed by about age 6 (Gathercole, Pickering, Ambridge, & Wearing, 2004). The capacity of each component increases from early childhood into adolescence (Gathercole, 1999; Gathercole et al., 2004). The executive is significantly linked to both storage devices beginning in early childhood. This finding indicates that the executive is associated with the coordination of the flow of information throughout WM (Baddeley, 1996; Gathercole et al., 2004), and different WM mechanisms develop in an integrated fashion from an early age. Finally, pSTM and visuospatial STM appear to develop relatively independently of each other, revealing their domain- specificity (Gathercole et al., 2004; Jarvis & Gathercole, 2003). WM capacity is assessed using various concurrent processing-storage tasks. In listening span tasks, children listen to sets of sentences that increase in number (e.g., “Pumpkins are purple” and “Fish can swim”) and are asked to respond to the truth value of each sentence (processing component) and recall as many sentence-final words from
  • 89. each set (storage component; Gathercole et al., 2004; Pickering & Gathercole, 2001). In counting span tasks, children count arrays of dots while remembering the sums of dots on each array; at the end of a set, they recall the sums from each array. In operation span tasks, children perform multiple arithmetic problems, store the answer to each problem or a separate word presented after each problem, and then recall all the answers or words at the end of the set. The developmental pattern is that processing accuracy is high while storage significantly improves. WM capacity is typically indexed by item recall—that is, availability of storage in the face of processing/interference. Much developmental work has focused on explaining increases in children’s WM capacity, examining the roles of the central executive and STM (Barrouillet & Camos, 2001; Barouillet, Gavens, Vergauwe, Gaillard, & Camos, 2009; Bayliss et al., 2005; Bayliss, Jarrold, Gunn, & Baddeley, 2003; Gathercole et al., 2004; Irwin-Chase & Burns, 2000; Karatekin, 2004). Research has shown that gains in capacity are associated with increases in both of these mechanisms. Some researchers have investigated the impact of processing speed/efficiency (Bayliss et al., 2005; Towse & Hitch, 1995; Towse et al., 1998). The idea behind the association between speed and WM capacity centers on the possibility that the slower the processing activity of a WM task is completed, the greater the opportunity for the stored items to decay or be forgotten. Only recently have researchers begun to investi- gate the collective contributions of STM and processing speed on WM performance (Bayliss et al., 2003, 2005; Magimairaj, Montgomery, Marinellie, & McCarthy, 2009). Bayliss et al. (2005) examined the individual and combined contributions of storage and processing speed on 6–10-year- old children’s WM capacity. Hierarchical linear regression and structural equation modeling showed that age-related increases in STM and processing speed contributed to
  • 90. Montgomery et al.: Working Memory and Language in SLI 79 developmental changes in WM capacity, with STM ac- counting for greater variance than speed. Magimairaj et al. (2009) replicated these findings in 6–12-year-old children. Some have argued that increases in WM capacity may also be driven by changes in attentional control. As children grow older they become better at rapidly switching their attention between the processing part of the task and remem- bering the items in STM (Barrouillet et al., 2009; Conlin, Gathercole, & Adams, 2005; Portrat, Camos, & Barrouillet, 2009). It is not difficult to see that attentional control (Engle, 2002; Unsworth & Engle, 2007) is closely related to the idea of scope or focus of attention (Cowan, 1997; Cowan et al., 2005) in that only a small bit of information can oc- cupy the focus of attention at any given moment. Relation of WM to Spoken Language Development and Functioning Lexical learning. Much developmental work investigat- ing the relation between WM and language has centered on word learning (Avons, Wragg, Cupples, & Lovegrove, 1998; Gathercole & Baddeley, 1990b; Gathercole, Willis, Emslie, & Baddeley, 1992). Most of this work has focused on pSTM, which has been argued to function as an important language learning device (Baddeley, Gathercole, & Papagno, 1998; Gathercole, 2006; Gathercole & Baddeley, 1990b). Word learning involves mapping sound to meaning. Using a variety of methods, robust associations between pSTM and new word learning have been reported for preschool-age children through about age 8 (Bowey, 2001; Gathercole & Baddeley,
  • 91. 1989, 1990b; Gathercole, Service, Hitch, & Martin, 1997; Jarrold, Thorn, & Stephens, 2009). The ability to hold novel speech material in pSTM presumably permits children to establish stable, long-term phonological representations of new words in long-term memory (e.g., Jarrold et al., 2009). As the lexicon grows, word entries become more phonolog- ically refined and better organized, with one organizational scheme involving words beginning with the same sound being stored together (Luce & Pisoni, 1998). Phonological STM and the ability to temporarily store new sound pat- terns may be an important factor in young children’s lexical learning and organization. Although the relation of pSTM and word learning weakens after age 8 (Gathercole, 1995; Gathercole, Tiffany, Briscoe, Thorn, & the ALSPAC Team, 2005), there continues to be a significant link through ado- lescence into adulthood (Atkins & Baddeley, 1998; Gupta, 2003). Morphological and syntactic learning and functioning. Some researchers (Plunkett & Marchman, 1993; Tomasello, 2000) argue that young children do not possess morpho- logical rules (e.g., past tense), grammatical categories (e.g., subjects, verbs, and objects), and syntactic structure (e.g., subject-verb-object [SVO] and passive). Rather, children initially learn whole phrases and only later discover under- lying rules, categories, and structures by using the distribu- tional properties/regularities of the input (Nelson, 1987; Plunkett & Marchman, 1993; Tomasello, 2000). Phonolog- ical STM may serve as a mediating or moderating mecha- nism for this analytic process. Some support for this idea comes from Adams and Gathercole (1995), who reported that pSTM predicts quantity and quality of spontaneous speech in 3-year-old children. They showed that high- pSTM capacity children, compared with low-capacity chil- dren, produced longer utterances containing a greater range
  • 92. of syntactic structures and lexical diversity. Blake, Austin, Cannon, Lisus, and Vaughan (1994) showed that STM is a better predictor of mean length of utterance in preschoolers than chronological or mental age. Because morphological and syntactic learning entails building relational knowledge, it is likely that several executive functions are involved; however, little empirical work has directly addressed the issue. The influence of WM capacity in language comprehen- sion is only beginning to receive attention. At the sentence level, the more controlled studies have focused on the relation of WM and complex sentence comprehension. WM has been linked to the comprehension of object relative clause forms (e.g., “The hippo that the lion kissed on the nose was running into the jungle”) in young children (Roberts, Marinis, Felser, & Clahsen, 2007). Children with greater WM capacity show more accurate comprehension than low-capacity children. Comprehension minimally involves storing a prior element (noun phrase [NP] 1) in WM while processing new, incoming input. However, WM capacity is likely just one important mechanism. Being able to reactivate a stored element and then integrate it into a developing local structure in a timely manner are other WM-related skills underlying complex sentence comprehension (Lewis, Vasishth, & Van Dyke, 2006; McElree, Foraker, & Dyer, 2003; Van Dyke, 2007). Support for this wider view comes from a recent study by Montgomery, Magimairaj, and O’Malley (2008). These authors showed that 6–12-year-old children’s spoken com- prehension of verbal be passives (“The little girl was kissed by the woman”) is associated with WM capacity and pro- cessing speed. At a more global level, children’s comprehen- sion of narrative is predicted by WM capacity and processing speed (Montgomery, Polunenko, & Marinellie, 2009). Be- cause narratives entail large amounts of input and keeping track of many representations, developing a coherent mental
  • 93. model requires the storage, retrieval, and rapid integration of multiple representations across large stretches of input. WM and Speed of Processing in SLI Relative to age peers, many children with SLI show significant limitations in nearly all WM mechanisms as well as speed of processing (see Table 1). Appreciation of these limitations and the relation of these limitations to the lan- guage deficits of these children have important practical implications. Such knowledge may translate into building more informed clinical profiles of these children’s cognitive- linguistic strengths and weaknesses. Such knowledge, in turn, may help inform clinical assessment, diagnosis, and treatment. STM Storage Many children with SLI show marked limitations in STM capacity. Gathercole and Baddeley (1990b) proposed the phonological storage deficit hypothesis of SLI, claiming that 80 American Journal of Speech-Language Pathology • Vol. 19 • 78–94 • February 2010 the language impairment in SLI is secondary to a deficit in phonological storage. Phonological STM is assessed using various tasks such as digit span, word span, and nonword repetition. In digit and word span, children are presented increasingly longer lists of items and recall each list in serial order. In nonword repetition, children imitate nonwords varying in length. Regardless of task, children with SLI gen- erally exhibit reduced pSTM relative to age peers (Archibald & Gathercole, 2006; Ellis Weismer et al., 2000; Gathercole
  • 94. & Baddeley, 1990b; R. Gillam, Cowan, & Day, 1995; Montgomery, 2004; Montgomery & Evans, 2009). Whether children with SLI evidence a developmental increase in STM capacity has been little studied. Gray (2004) reported an increase in capacity between 3 and 6 years. How- ever, capacity may level off by about 11 years, as suggested by findings of a longitudinal study by Conti-Ramsden and Durkin (2007). Their findings are inconsistent with the de- velopmental literature showing that pSTM capacity does not asymptote until about 14–15 years in TD children (Gathercole, 1999; Gathercole et al., 2004). Finally, there is evidence that the STM deficit of children with SLI may be confined to the verbal modality, as children with SLI and age peers tend to perform similarly on visuospatial STM tasks (Alloway & Archibald, 2008; Archibald & Gathercole, 2006, 2007). Central Executive It has only been recently that SLI researchers have begun to study the central executive, primarily in the context of WM tasks. Aspects of the executive that have been assessed include attentional capacity and several attentional functions— that is, allocation, inhibitory control, updating, and sustained attention. Attentional capacity. Attentional capacity refers to the limited mental activation/energy available to a person to perform a given task (Just & Carpenter, 1992). Most SLI studies have tested attentional capacity using verbal tasks (Ellis Weismer, Evans, & Hesketh, 1999; Mainela-Arnold & Evans, 2005; Montgomery, 2000a), but some investigators have also begun to include nonlinguistic tasks (Alloway & Archibald, 2008; Archibald & Gathercole, 2006, 2007; Windsor, Kohnert, Loxtercamp, & Kan, 2008). Irrespective
  • 95. of the nature of the task, many children with SLI show re- duced performance relative to age peers. Ellis Weismer et al. (1999) compared the attentional capacity of children with SLI and age peers. Using the Competing Language Processing Task (CLPT; Gaulin & Campbell, 1994), these investigators reported that both groups yielded similar comprehension, but the SLI group yielded significantly poorer word recall. Similar results have been reported by others (Archibald & Gathercole, 2006, 2007; Mainela-Arnold & Evans, 2005; Marton & Schwartz, 2003; Montgomery, 2000a, 2000b; Montgomery & Evans, 2009). Because all these studies show that children with SLI can manage both comprehension and recall when the demands for recall are light (i.e., few items need to be recalled), the interpretation has been that children with SLI have reduced attentional capacity compared to age peers. Archibald and Gathercole (2006, 2007) and Windsor et al. (2008) have extended these findings and interpretation to the nonlinguistic domain. Im-Bolter, Johnson, and Pascual-Leone (2006) cor- roborated the capacity limitation hypothesis using a variety TABLE 1. Working memory (WM) and processing speed of children with specific language impairment (SLI) relative to age-matched peers. WM/speed Relative to age peers Short-term memory capacity Verbal storage Poor (Archibald & Gathercole, 2006, 2007; Ellis Weismer et al., 2000; Gathercole & Baddeley, 1990b; Montgomery, 1995, 2004) Visuospatial storage Similar
  • 96. (Alloway & Archibald, 2008; Archibald & Gathercole, 2006, 2007) WM capacity Concurrent processing stor- age Poor (Archibald & Gathercole, 2006, 2007; Ellis Weismer et al., 1999; Marton & Schwartz, 2003; Montgomery, 2000a, 2000b; Montgomery & Evans, 2009) Central executive Attentional capacity Poor (Archibald & Gathercole, 2006, 2007; Ellis Weismer et al., 1999; Im-Bolter et al., 2006; Mainela-Arnold & Evans, 2005; Montgomery & Evans, 2009) Attentional allocation/shift- ing Similar (Montgomery, 2000a, 2000b; Im-Bolter et al., 2006) Updating Poor (Im-Bolter et al., 2006) Inhibition Poor (Im-Bolter et al., 2006; Marton et al., 2007; Seiger-Gardner & Schwartz, 2008) Sustained attention Poor
  • 97. (Finneran et al., 2009; Montgomery, 2008; Montgomery, Polunenko, & Marinellie, 2009; Spaulding et al., 2008) Processing speed Poor (Leonard et al., 2007; Miller et al., 2001; Windsor & Hwang, 1999; Windsor et al., 2008) Montgomery et al.: Working Memory and Language in SLI 81 of independent measures of attentional capacity. Collectively, such findings and interpretation are consistent with the gen- eral WM literature characterizing attentional capacity as a domain-general cognitive attribute (Baddeley, 1996; Cowan, 1997; Cowan et al., 2005; Unsworth & Engle, 2007). Finally, it is not clear whether children with SLI exhibit develop- mental increase in attentional capacity, as there are no studies directly addressing the issue. Attentional control. Im-Bolter et al. (2006) evaluated three attentional control functions in children with SLI. Using a variety of independent tasks, they assessed shifting, updating, and inhibitory control. Shifting, which is roughly analogous to Baddeley’s (1996) resource allocation, is the ability to devote attention between two different levels of a task (e.g., the processing and storage parts of a WM task) or to two different tasks (Im-Bolter et al., 2006). Updating refers to maintaining focus at a given level of a task and adding new content to the focus of attention (e.g., adding to a list of to-be- remembered items in storage in a WM task). Inhibition refers to preventing irrelevant stimuli from entering WM or focus