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Copyright © 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.
Pragmatics and Adult Language Disorders
10 April 2007 (online)
For nearly three decades, clinicians and researchers have been actively investigating the relationship of pragmatics to language pathology. This investigation was originally motivated by the need to assess and treat clients whose communication difficulties did not fall so obviously into the dominant syntactic and semantic frameworks of the day. The focus of these early enquiries was on developmental language disorders and, particularly, on children whose communication problems bore some resemblance to those seen in the childhood psychopathologies (e.g., autism). These early discussions had several notable successes, one of which was the emergence of a new diagnostic category of semantic-pragmatic disorder in children.  They also helped to establish pragmatics firmly as an area of enquiry that practitioners of speech-language pathology could ill afford to neglect.
Many years on, our knowledge of normal and disordered pragmatics in children is at least as well developed as our knowledge of normal and deviant structural language in children. We now have a clear sense of the order in which normally developing children acquire key pragmatic milestones such as the ability to use and comprehend a range of speech acts. Much is now known about the nature and extent of pragmatic impairment in children from diverse clinical populations. The highly developed state of our knowledge of pragmatics in normally developing and disordered children is in stark contrast to our rather limited understanding of pragmatic impairment in adults with language disorder. The less developed state of our knowledge in this area can be attributed in large part to two traditional assumptions. The first of these assumptions is that pragmatic deficits in adults are largely the province of right-hemisphere damage. Through its association with left-hemisphere damage, aphasia is generally seen to be a structural language impairment with few implications for the pragmatic language skills of affected individuals. The second assumption is that pragmatic impairments, to the extent that they exist in adults, are generally the consequence of structural language impairments (e.g., in aphasia) or cognitive deficits (e.g., in traumatic brain injury). In other words, pragmatic deficits are secondary, not primary disorders in these clients. The corollary of this assumption is that it is structural language and cognitive deficits that should be the target of intervention-pragmatic impairments will improve, it is assumed, as soon as these underlying language and cognitive deficits resolve. If the child literature has taught clinicians in adult language pathology anything, it is that structural language skills are not necessarily a strong predictor of pragmatic language skills (e.g., witness the relatively intact pragmatic skills of children with specific language impairment) and that cognitive deficits hold only the most tenuous relationship to pragmatic skills (e.g., the Down's syndrome child has less pragmatic impairment than the autistic child with normal intelligence). These lessons could be used to good effect to dismantle some rather unhelpful, yet pervasive assumptions concerning pragmatic impairment in adult language disorders.
This dedicated issue of Seminars in Speech and Language is timely for two reasons. First, the bulk of published literature in pragmatic disorders examines children with language disorders. Journal articles and book chapters that examine pragmatic impairments in adult language disorders are still relatively uncommon. The exception is the language disorder in schizophrenia, which has been extensively discussed in relation to pragmatic disorders. However, all other acquired language disorders, whether these are the result of cerebrovascular disease, traumatic brain injury, or neurodegenerative disorders (e.g., Alzheimer's disease), are underrepresented in discussions of pragmatic disorders. Second, work in clinical pragmatics should reflect current thinking and developments within the theoretical study of pragmatics. Also, practitioners and clinical researchers can contribute important insights to theoretical pragmatics. This issue of Seminars will help achieve a necessary synthesis of ideas and approaches across theoretical and clinical branches of pragmatics.
In my own contribution to this issue-“Pragmatics and adult language disorders: past achievements and future directions”-I examine the current state of our knowledge of pragmatic disorders in adults with language impairment. This article presents a brief historical overview of the emergence of clinical pragmatics in adult language pathology. Pragmatic deficits in five clinical populations are reviewed: left-hemisphere damage, right-hemisphere damage, traumatic brain injury, neurodegenerative disorders (with emphasis on Alzheimer's disease), and schizophrenia. Current gaps in our understanding of adult pragmatic disorders are identified and presented as “future directions” for research in clinical pragmatics.
The cognitive basis of many acquired pragmatic disorders is undeniable. Yet, the cognitive domain is still largely overlooked by researchers in speech-language pathology. In his article “Cognitive pragmatics of language disorders in adults,” Albyn Davis seeks to bring the relatively new discipline of cognitive pragmatics to the attention of speech-language pathology practitioners and researchers. After discussion of the scope and methodology of cognitive pragmatics, Davis analyzes the findings of several priming experiments. Among the central pragmatic phenomena assessed by these experiments are inference generation, metaphor interpretation, and the comprehension of ironic/sarcastic utterances by (variously) aphasic adults, closed head-injured adults, and adults with right-hemisphere dysfunction. A concept of increasing significance to clinical pragmatics-theory of mind-is also discussed.
Clinicians have long recognized that standardized language batteries are poorly equipped to assess the often subtle pragmatic deficits that occur in adult language disorders. This is particularly true in the case of adults who sustain a traumatic brain injury. Many of these adults can perform within normal limits on assessments of structural language but nevertheless present with significant, chronic communication difficulties that adversely affect quality of life. This population presents clinicians with a further assessment challenge in that communication disorders are often accompanied by complex cognitive deficits. Discourse analysis, Carl Coehlo argues, has been shown to have clinical utility in the assessment of TBI clients. In his article “Management of discourse deficits following TBI,” Coehlo examines a range of monologic and conversational discourse procedures that have been used to assess the discourse skills of this population. Coehlo also discusses several practical and theoretical considerations that have restricted the clinical use of these procedures. Chief among them is the difficulty of translating research findings of discourse impairments into treatment programs. Several discourse treatment approaches are reviewed. Coehlo concludes by emphasizing the need for discourse treatments to be theoretically motivated.
An approach that avoids setting out with predefined notions of conversational adequacy and competent communicative behavior is conversation analysis (CA). In their article “Using conversation analysis to assess and treat people with aphasia,” Beeke, Maxim, and Wilkinson discuss the principles that are integral to CA methodology. These authors describe the application of CA to the assessment of aphasia within an examination of two published assessments, the Conversation Analysis Profile for People with Aphasia (CAPPA) and Supporting Partners of People with Aphasia in Relationships and Conversation (SPPARC). CA may also be used in aphasia therapy. Using two case studies, Beeke, Maxim, and Wilkinson demonstrate how conversational behaviors that are judged to be disruptive by the participants in conversation may first be identified through CA techniques and then modified. The authors' analysis is supported by detailed transcripts of interactions between people with aphasia and their habitual conversation partners.
Most studies of pragmatics in adults with acquired neurogenic disorders focus on deficits in pragmatic skills. This is also true of the articles in this issue. In their article “Pragmatics in discourse performance: insights from aphasiology,” Ulatowska and Olness argue that the pragmatic abilities of adults with mild to moderate aphasia are generally well preserved. To support their claim of preservation, these authors demonstrate that aphasic adults are able to satisfy certain requirements of coherent discourse. In specific terms, these adults employ temporal-causal organization within discourse. They are also able to select information that builds themes and highlight information through the use of evaluative devices. Each of these ways of achieving coherence in discourse is illustrated through the analysis of personal narratives that are told by individuals with aphasia.
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