Developmental Language Disorder (DLD) is diagnosed when the child may be experiencing problems in both the content (semantics) and the form of language (phonology, morphology, and syntax) with no known underlying biomedical condition such as brain injury or autism spectrum disorders, ASD [1
]. It is important to highlight that DLD is a heterogeneous condition. Deficits in the acquisition and use of language can be noticed in the reduced vocabulary, limited structure of the sentences, and errors in discourse. The areas commonly affected in DLD (focusing on oral language) are phonology, syntax, word finding and semantics, discourse, verbal learning, and memory, but difficulties also occur in reading and writing. Children with DLD may have problems with language use in social interactions, i.e., pragmatics [2
]. These problems can have secondary effects in other areas related to social contexts, such as socialization, communication, socioemotional problems, or academic achievement [4
]. According to Bishop and Norbury [7
], there is a particular group of children who have fluent, complex, and clearly articulated expressive language, despite showing severe problems in the way the language is used socially. This condition is commonly known as Pragmatic Language Impairment (PLI), or what has more recently been called Social Communication Disorder (SCD; Diagnostic and Statistical Manual of Mental Disorders, DSM-5 [8
]; see Davies, Andrés-Roqueta and Norbury [2
] for a discussion on whether pragmatic language skills of children with SCD may elucidate sources of pragmatic breakdown in other developmental populations such as autism). With all these difficulties, early diagnosis is crucial because children with DLD have a greater risk of experiencing poor social, emotional, and mental health outcomes [9
], which in turn increases the probabilities of them becoming victims of bullying [13
Information about children’s language and communication development can be obtained in different ways: on the one hand, information about a child’s performance in natural contexts can be provided by parents or teachers and, on the other hand, practitioners also assess children with different formal measures. Standardized tests are important because they are a valid way to find the profile of the individual and any possible deficits. In this sense, both reports and formal assessments are considered an important source of information for establishing a meaningful and contextualized diagnosis [14
]. Nonetheless, it is worth mentioning that formal assessments require controlled situations, and this therefore represents a contextual limitation for professionals who do not have access to the information about the children’s daily life in more natural contexts, such as at home or school. In these situations, children usually display more natural behaviors, which afford clinical observations and/or assessments [16
There are different reports to be answered by parents that provide valuable information when children are not yet able to answer for themselves (e.g., Rossetti Infant Toddler Language Scale [17
]) or, as in the case of the Social Communication Questionnaire (SCQ, [18
]), that are widely available as screening tools; however, the SCQ was designed specifically for detecting risk for ASD, not for DLD. Most language tests or reports assess language structure and content, but are less well suited for evaluating how children use and interpret language or for identifying communication problems, e.g., poor turn-taking or over-literal comprehension [19
In this regard, there is a widely used instrument that employs indirect measures to assess communication behaviors in children: the Children’s Communication Checklist revised (CCC-2). This questionnaire is answered by parents, although it can be completed by any adult who has had regular contact with the child at least 3–4 days per week for at least 3 months, and it provides information about the language and communication profiles in different contexts of interaction (i.e., home or school). Originally, the CCC was designed by Bishop [21
] to obtain a quick and easy evaluation measure of children with DLD, predominantly with pragmatic language impairment. Subsequently, the CCC was revised by Bishop in 2003 and standardized with 542 typically developing (TD) children, resulting in the CCC-2. One year later, the CCC-2 was validated with children with diagnoses such as DLD, PLI, and different levels of autism [3
The CCC–2, with its 70 items spanning 10 subscales, was built to assess different measures of language and communication skills in children from 4 to 16 years of age [22
]. Comparisons and results of the CCC-2 have usually been performed based on two overall scores: a general communication composite (GCC), which evaluates children’s communication skills, and a social interaction difference index (SIDI), which specifically assesses children’s pragmatic language. Bishop [22
] demonstrated that children with DLD are expected to have difficulty with scales related to structural language, and to do relatively better with scales concerning pragmatics and autistic behavior. Moreover, they would be more likely to obtain a mean GCC below 100. Given the differences in the main composite scores, most studies have employed the CCC-2 as a useful questionnaire that discriminates children with clinical communication problems from typically developing children, as well as differentiating children with DLD from children with pragmatic language impairments. To our knowledge, no research has correlated the subscales with other formal measures or tests.
The CCC-2 was adapted and translated into different languages and went on to become an international tool. The Dutch version of the CCC-2 was used to distinguish the language profiles of children with ASD, DLD, and attention deficit hyperactivity disorder (ADHD) [23
]. Moreover, the Dutch version of the CCC-2 added a new pragmatic score called the General Pragmatic Score (GenPragS), which is comparable to the Pragmatic composite score of the original CCC. However, the subscale (D) coherence was added, which was previously classified as a communication skill, but researchers realized that some items referred to pragmatics [20
]. The Norwegian version of the CCC-2 successfully differentiated between a group of language-impaired and non-language-impaired children [24
]. The Serbian version of the CCC-2 [25
] was redefined by Glumbić and Brojčin [26
] to obtain three subscales—General Communication Ability, Pragmatics, and Structural Language Aspects—that would distinguish between clinical samples (ASD, ADHD, DLD). The reliability and validity of the CCC-2 was also found in French in Quebec [27
], Portuguese [28
], and Spanish [29
]. Finally, the Spanish version of the CCC-2 was also used to determine whether the CCC-2 was able to identify pragmatic profiles and discriminate between normative and clinical profiles such as significant language difficulties) or Down syndrome [30
As mentioned above, the CCC-2 has been widely used with the aim of identifying different communication profiles in children with DLD, ADHD, and ASD [21
]. However, the CCC-2 has also been used as a quick screening tool for identifying language disorders in children with sex chromosome trisomies [39
], auditory processing disorder [40
], schizophrenia [42
], sleep problems [43
], William syndrome [44
], and in deaf children with cochlear implants [45
]. However, none of these studies have used structural language, pragmatics, social cognition (SC, the ability to attribute mind to others and ourselves) or executive function (EF, a set of cognitive processes that are necessary for the cognitive control of behavior) tests as predictive measures of the CCC-2 scales, although they are considered key predictors of pragmatics [46
It has been shown that the CCC-2 is a quick and reliable tool that allows professionals to gain a global vision of the problems of language and communication skills that the child may have. In this respect, although they are widely used, formal measures to assess children’s sociocognitive and linguistic profile are usually time-consuming. However, the assessment of pragmatics is difficult and complex [47
]. It is a complex area because it is related not only to the use of language in context, but also to SC [46
]. Pragmatics and SC are related by definition, given that pragmatic ability underlies the capacity to use and interpret language appropriately in social situations. Studies using screening instruments and conversational analysis have reported pragmatic deficits among children with DLD [3
]. Similarly to ASD (but with fewer empirical studies conducted in the area), research based on experimental tasks has described problems in specific areas of pragmatics such as understanding figurative language [48
], sensibility to conversational maxims like “quantity” [51
] and other Gricean maxims [53
], using the preceding context to resolve ambiguous utterances and in narrative production [54
], or understanding graphic humor [56
]. Their pragmatic skills are usually in keeping with the levels of their structural language, as they perform as well as younger TD children matched for language level in experimental tasks [51
]. Moreover, their level of SC also matters for these pragmatic problems when the tasks are socially oriented [57
One of the most widely used SC measures is the Strange Stories task [58
]. This task allows pragmatic impairment to be detected in children with DLD and ASD, because children must grasp the speaker’s real intention by understanding his/her utterance (sometimes non-literal) and contextual aspects concerning the communicative situation [46
]. The Strange Stories task involves stories about sarcasm, irony, and white lies, among other things. For example, in the ironic story, a character uses an utterance (“Well, that’s very nice, isn’t it!”) to remark that a person is being rude. Thus, the participant must use his or her structural language competence to understand the literal meaning, and may understand the context and pragmatic maxims for the “hidden” intended meaning [51
]. Interestingly, there is no empirical evidence from studies using the CCC-2 pragmatic subscales and establishing relationships with SC tasks.
Likewise, very little work has explored the relationships between pragmatics and EF in children with DLD. The rules of conversation change depending on the context in which they occur, and therefore they allow us to adapt our speech flexibly to the dynamic demands of the context by being flexible, tight, and effective [60
]. Furthermore, maintaining a coherent reciprocal conversation requires paying attention and remembering what our speaker is saying (therefore using our attention and working memory skills). At the same time, we also need to inhibit excessive talking and ensure that our contribution is relevant (thus using our inhibition, organizing, monitoring, and planning skills) (see Green et al. [61
] for a review).
The novelty of the present study is the fact that it has broken the CCC-2 down into simple scales (structural language, pragmatics, and autistic subscores) for associations and predictions with formal measures of structural language, pragmatics, SC, and EF. The present paper thus aims to examine whether parental information provided by the CCC-2 questionnaire is significantly associated with formal measures of structural language, pragmatics, EF, and SC in children with DLD. In this regard, the following hypotheses are stated:
Hypotheses 1 (H1).
First, the responses given by the parents are expected to show the language and communication problems of their children according to their age.
Hypotheses 2 (H2). Second, the CCC-2 scales (structural language, pragmatics, and autistic subscores) are expected to be associated with clinical-related tests (i.e., the scales of structural language will correlate to phonetics, syntax, and vocabulary tests; the pragmatic and autistic scales will correlate with SC, EF, and pragmatics) . Hypotheses 3 (H3).
Finally, formal measures are also expected to predict the CCC-2-related scales (i.e., the scales of structural language will correlate with the phonetics, syntax, and vocabulary tests; the pragmatic and autistic scales will correlate with SC, EF, and pragmatics).
3.1. Descriptive Statistics and between-Group Comparisons on Formal Measures
reports the descriptive statistics of the four groups for grammar, age, structural language, pragmatics, SC, and EF formal measures.
The Mann–Whitney U-test showed that the groups did not differ in age (U = 560.500, p < 0.001, r = 0.036) and small effect sizes were observed. Moreover, a Chi-squared test showed that groups did not differ according to gender (χ2 = 0.20, p = 0.887).
As regards the formal measures (raw scores) of structural language, pairwise comparisons revealed that the DLD and AM groups differed in all the measures: phonetics, expressive grammar, receptive grammar, receptive vocabulary, expressive vocabulary, and also in the structural language composite score. Large-size effects were observed for grammar and phonetics measures, as well as for the composite score, whereas medium-size effects were observed for vocabulary measures.
Regarding pragmatic scores, between-group comparisons revealed differences between the DLD and the AM groups: receptive pragmatics, expressive pragmatics, and pragmatics composite score. Large-size effects were observed for all cases.
Regarding the social cognition measure, between-group comparisons revealed differences between the DLD and the AM groups, and large-size effects were observed.
Finally, turning to the executive function measures, again, between-group comparisons showed that the AM group achieved a significantly lower performance than the DLD group: sustained attention, latency of response, and EF composite variable, and large- and medium-size effects were observed.
3.2. Descriptive Statistics on CCC-2
reports the descriptive statistics on the CCC-2 for the DLD group.
As regards the GCC score (scaled scores), the DLD group obtained a mean of 67.53, which is almost the cutoff range of language impairments.
As regards the SIDI index (scaled scores), the DLD group obtained a mean of 10.07, which is a value that is included within normal limits (the normal range of SIDI scores is from −10 to 10).
As regards Structural language (scaled scores), the DLD group obtained a mean of 28.57; as regards Pragmatics (scaled scores), the DLD group obtained a mean of 28.57; and as regards the Autistic index (scaled scores), the DLD group obtained a mean of 18.53.
Individual scores demonstrate that the DLD group showed better performance on scales E, F; then on D, G, H; then I and C; and the lowest means were obtained on A and B.
3.3. Correlations between CCC-2 Scores and Age, Structural Language, Linguistic Pragmatics, Social Pragmatics and Executive Functions
Zero-order nonparametric correlations (Spearman) between key measures are presented in Table 4
First, the three scores derived from the CCC-2 proved to be positively and strongly correlated: Structural Language–Pragmatics (p < 0.001); Structural Language–Autistic index (p = 0.001); Pragmatics–Autistic index (p = 0.003).
Strong and negative correlations were observed between Structural Language measured with the CCC-2 and age (p < 0.001), the structural language composite score based on formal measures (p < 0.001), and the executive functions composite score (p < 0.001). Moreover, a medium and negative correlation was observed with pragmatics (p = 0.014). However, it was not correlated with social cognition (p = 0.055). The correlations are negative because raw scores on the CCC-2 indicate the degree of difficulty on the different scales (in contrast to scaled scores).
For the Pragmatic measure of the CCC-2, a negative and non-significant correlation was observed with age (p = 0.219). Medium and negative associations were observed with formal measures of structural language (p = 0.014), pragmatics (p = 0.028), social cognition (p = 0.011), and executive functions (p = 0.005). Again, the correlations are negative because raw scores on the CCC-2 indicate the degree of difficulty on the different scales.
Finally, for the Autistic measure of the CCC-2, a negative and non-significant correlation was observed with formal measures of age (p = 0.139), pragmatics (p = 0.246), and social cognition (p = 0.134). Medium and negative associations were observed with formal measures of structural language (p = 0.014) and executive functions (p = 0.010). Again, the correlations are negative because raw scores on the CCC-2 indicate the degree of difficulty on the different scales.
3.4. Predictive Analysis of the CCC-2 Scores of Structural Language, Pragmatics and Autistic Indexes
As shown in the correlation analyses, several variables were correlated in the DLD group, making it difficult to identify the independent contribution each of them makes to the CCC-2 measures. To further investigate the contribution of these variables, three hierarchical linear regression analyses were conducted for the DLD group (n = 30).
Structural Language (CCC-2: A + B + C + D), Pragmatics (CCC-2: D + E + F + G + H), and Autistic score (CCC-2: I + J) were the outcome variables in the regression, and five predictor variables were entered in the following order (Table 5
and Table 6
): age was entered first, as raw scores had been used, and also because there was an important age difference between some participants in the sample (ranging from 3 to 9 years old). The Structural Language composite score (formal measure) was entered next, because structural language deficits are fundamental factors for the pragmatic deficits observed in children with DLD (e.g., [51
]). Pragmatic and social cognition scores were entered after structural language to investigate whether they make a specific contribution to each CCC-2 score when structural language skills have been taken into account. Finally, the executive function composited variable was introduced in the final stage, to check whether other features related to sustained attention and latency of response are relevant.
For Structural Language (CCC-2), the general model was significant and accounted for 64% of the variance, F (5, 23) = 8.225, R2
= 0.641, p
< 0.001 (see Table 5
). Higher Structural Language scores on the CCC-2 were negatively and significantly associated with Age, which explained 37% of the variance, and higher structural language scores of formal measures, which explained 23% of the variance. No single association was found with the formal assessments on pragmatics, social cognition, or executive functions.
For Pragmatics (CCC-2), the general model was significant and accounted for 37% of the variance, F (5, 23) = 2.692, R2
= 0.369, p
= 0.047 (see Table 6
). Higher Pragmatic scores on the CCC-2 were negatively and significantly associated with structural language formal measures, which explained 16% of the variance. No single association was found with the formal assessments on age, pragmatics, social cognition or executive functions.
Finally, for the Autistic index (CCC-2), the general model was not significant: F (5, 23) = 1.296, R2 = 0.220, p = 0.300. In this sense, no single association was found with formal measures of age, structural language composited score, pragmatics, social cognition or executive functions.
The present study attempted to determine whether the Spanish version of the CCC-2, applied to parents of children with DLD, agrees with clinical information when linguistic, pragmatic, EF, and SC areas are assessed through direct measures. Furthermore, this information from parents allows us to better understand the children’s problems, in a more detailed and contextualized way than with only the results of direct measures.
Regarding the first hypothesis, the responses given by parents were expected to allow us to better understand the problems of language and communication that children with DLD have. First, all the formal measures discriminated between the two groups (DLD–AM), demonstrating that the performance of those with DLD was lower than that of their AM peers in structural language, pragmatics, SC, and EF measures, in line with previous studies (for structural language and pragmatics: [46
]; for SC [46
]; and for EF [60
]). Also, regarding previous findings using other versions of the CCC-2 (e.g., Norwegian sample), a cutoff at or below a scaled score of 64 on the GCC was selected to identify children with language impairments [24
]. Our sample was closer to the cutoff, which would corroborate their problems in structured language. Moreover, taking a closer look at the scales, their lower means were found in (A) Speech and (B) Syntaxis. However, the children with DLD obtained a positive score (within normal limits) in the SIDI, indicating no disproportionate pragmatic impairments according to their structural language abilities. Again, a more detailed observation shows that the best scores of the children with DLD were found on the pragmatic scales (E > F > D > G > H).
With regard to Hypothesis 2, the CCC-2 scales were associated with the different clinical-related tests (formal measures). In this sense, Structural Language (CCC-2) was correlated with age, structural language, pragmatics, and EF (but not with SC); Pragmatics (CCC-2) was correlated with structural language, pragmatics, SC, and EF (but not with age); and the Autistic index (CCC-2) was correlated with structural language and EF (but not with age, pragmatics, or SC). All the CCC-2 correlations were in line with what was expected for Structural Language and Pragmatic scores, but not for the Autistic index, which was expected to also correlate with SC. SC and Pragmatics would go hand in hand for the complete understanding of the contextual aspects around the communicative situation [46
]. In the same sense, EF would seem to be crucial to remember the interlocutor’s information, monitoring, and planning the speech or to know when it would be better to initiate a conversation [60
It is important to note the significant correlations found on comparing parents’ opinions and the clinical measures. In this regard, it was found that parents’ and professionals’ criteria ran in the same direction, which is useful for detecting and recognizing their children’s language and communication handicaps. It should be highlighted that parents’ information would be useful not only in the aspects referring to the structural language (phonology, morphosyntax, and semantics), but also in the pragmatics areas, which are less easily measurable in the clinical setting (inadequate initiation, context, non-verbal communication). Thus, it is concluded that the parents’ opinions agree with the clinical assessments.
Together, these findings identify structural language, pragmatics, SC, and EF as key skills for communication in the DLD group.
Finally, in Hypothesis 3, results corroborated the idea that formal measures predicted the CCC-2 scales related to structural language and pragmatics. On the one hand, age and structural language predicted the structural language index (CCC-2), which makes sense as the errors in phonetics, syntax and vocabulary affect the structural language index (CCC-2), and, in the same line, the formal measures of structural language. On the other hand, structural language predicted the Pragmatic Index (CCC-2), but not age or formal measures of pragmatics, EF, and SC. Again, this could be explained by the need to use the structural language competence to understand the literal meaning at first to fully comprehend the hidden intention or the context where the utterance is made [51
]. Finally, none of the formal measures predicted the Autistic Index, which could be explained by the fact that the sample consisted only of children with DLD (non-autistic children) with specific difficulties in structural language and pragmatics, rather than SC and EF.
Specifically regarding pragmatic competence, between-group comparisons confirmed that children with DLD faced significant difficulties on the formal measures (including structural language, pragmatics, SC, and EF tasks) compared with their AM peers. However, difficulties with pragmatics were in keeping with the participants’ structural language (but not SC or EF). This issue emphasizes the role of structural language in pragmatic development for children with DLD, obtaining similar findings to those of previous research (e.g., [2
]; for a complete review, see [46
As a limitation, we must be cautious with our results. First, a larger sample size would be needed in future studies to be able to conduct a meticulous study of the overlap between structural language, SC, EF, and pragmatics. Moreover, most of the participants in the present study are still developing some of the skills measured, so the results of the present study are applicable to children with DLD from 4 to 9 years old, but not for older ones. In this sense, most of the studies cited have assessed samples of older children with DLD, and pragmatic problems are perhaps more salient and best predicted by SC or EF, instead of only structural language. Furthermore, the Spanish language entails greater difficulties in morphological inflections compared to English (gender and number concordance, or verb conjugations). Other cultural influences that are more related to pragmatic aspects could exert an influence (e.g., accepted distance between interlocutors, improper initiation, or turn-taking behavior accepting more interruptions). Finally, there is a need for further research on the exact characterization of the different pragmatic skills and whether they depend on the phenomenon under study (e.g., figurative understanding, gesture–speech integration or understanding irony), on the structural aspects linked to understanding the linguistic context, on the SC strategies of the listener, or on the EF skills to maintain and initiate communication with other people [46
]. In this respect, after examining the results, training of structural language skills seems essential for the development of pragmatic skills in children with DLD between 4 and 9 years of age. Furthermore, it is important to remember that the pragmatics subtest of ELI may not be enough to measure the child’s pragmatic competences in an exact and complete way. In fact, it is a quick measure that can give us an initial idea. However, this subtest cannot be compared with pragmatic tests in which the evaluation is based on natural observation, through the behavior of the participants in a specific context. In Spanish, professionals and practitioners need more complex formal batteries to assess pragmatic competences in a comprehensive way.
In sum, the results of the present study responded to our main goal. The parents’ reports on the CCC-2 were consistent with the professionals’ formal evaluations. Another conclusion that could be drawn is that the extent and underlying causes of general communication difficulties of children with DLD correlate not only on the children’s competence with structural language and pragmatics, but also on SC and EF. Nevertheless, structural language seems to be the best predictor of all the subscales measured with the CCC-2.
It is important to highlight that, on the one hand, parents’ responses have been seen as important and complementary cues to complete the important information about children’s communicative skills in different contexts. Furthermore, it should be highlighted that the CCC-2 is an informative, fast, and cost-effective tool to measure and anticipate language impairments in preschool and school-age children. Since parents can participate, clinicians can have access to the children’s daily life in a more natural context than in a clinical setting. It should be added that, according to our data, the information provided by the parents seems to be precise in structural language aspects (the most visible in communication), but they do not seem to be aware of the actual pragmatic implications/difficulties, as some pragmatic skills develop during later childhood. In this regard, clinicians should make parents aware of these difficulties and help them with guidelines for intervention in pragmatic aspects. Future research should investigate the use of these kinds of tools with larger samples, while also adding more sophisticated items to address pragmatic components, given that they are more difficult to evaluate in designs involving children.
Moreover, as demonstrated in the present study, structural language skills affect the general communication of a child with DLD. Therefore, focusing only on pragmatics without taking into account other structural language will not reveal the actual communication needs of a child with DLD and might result in treatment goals that are too tightly defined [34
Consequently, multi-disciplinary assessments of the communication profile of a child with DLD are necessary to design an adapted and individualized intervention (e.g., include formal assessments together with parents’ reports on aspects of communication). Moreover, it seems very important to include structural language contents in interventions that aim to improve pragmatic competence [51
]. However, it would also be important to include aspects of SC (e.g., regarding the understanding of a speaker’s intention) and EF (e.g., regarding attention to cues from context, or impulsive or quick responses to the speaker) to improve other social communication skills that have not been addressed with the CCC-2 (e.g., understanding irony). Early diagnosis of pragmatic difficulties is crucial due to the fact that children with DLD are at greater risk of experiencing poor social, emotional, and mental health outcomes [9
], which increases the probabilities of them being the victim of bullying [13