INT J LANG COMMUN DISORD, MAY–JUNE 2012,

VOL. 47, NO. 3, 233–244

Research Report
The Social Communication Intervention Project: a randomized controlled
trial of the effectiveness of speech and language therapy for school-age
children who have pragmatic and social communication problems with
or without autism spectrum disorder
Catherine Adams†, Elaine Lockton†, Jenny Freed†, Jacqueline Gaile†, Gillian Earl‡, Kirsty McBean†,
Marysia Nash§, Jonathan Green¶, Andy Vail¶ and James Law∗
†
Human Communication and Deafness Division, University of Manchester, Manchester, UK
‡
NHS Lothian, Edinburgh, UK
§
Speech and Language Therapy Department, Royal Hospital for Sick Children, Edinburgh, UK
¶
Child and Adolescent Psychiatry, University of Manchester, Manchester, UK
∗
School of Education, Communication and Language Sciences, University of Newcastle, Newcastle, UK

(Received August 2011; accepted December 2011)

Abstract
Background: Children who show disproportionate difficulty with the pragmatic as compared with the structural
aspects of language are described as having pragmatic language impairment (PLI) or social communication disorder
(SCD). Some children who have PLI also show mild social impairments associated with high-functioning autism or
autism spectrum disorder (ASD). There is little robust evidence of effectiveness of speech–language interventions
which target the language, pragmatic or social communication needs of these children.
Aims: To evaluate the effectiveness of an intensive manualized social communication intervention (SCIP) for
children who have PLI with or without features of ASD.
Methods & Procedures: In a single-blind RCT design, 88 children with pragmatic and social communication needs
aged 5;11–10;8, recruited from UK speech and language therapy services, were randomly assigned in a 2:1 ratio
to SCIP or to treatment-as-usual. Children in the SCIP condition received up to 20 sessions of direct intervention
from a specialist research speech and language therapist working with supervised assistants. All therapy content
and methodology was derived from an intervention manual. A primary outcome measure of structural language
and secondary outcome measures of narrative, parent-reported pragmatic functioning and social communication,
blind-rated perceptions of conversational competence and teacher-reported ratings of classroom learning skills
were taken pre-intervention, immediately post-intervention and at 6-month follow-up. Analysis was by intention
to treat.
Outcomes & Results: No significant treatment effect was found for the primary outcome measure of structural
language ability or for a measure of narrative ability. Significant treatment effects were found for blind-rated
perceptions of conversational competence, for parent-reported measures of pragmatic functioning and social
communication, and for teacher-reported ratings of classroom learning skills.
Conclusions & Implications: There is some evidence of an intervention effect on blind and parent/teacher-reported
communication outcomes, but not standardized language assessment outcomes, for 6–11-year-old children who
have pragmatic and social communication needs. These findings are discussed in the context of the increasingly
central role of service user outcomes in providing evidence for an intervention. The substantial overlap between
the presence of PLI and ASD (75%) across the whole cohort suggests that the intervention may also be applicable
to some verbally able children with ASD who have pragmatic communication needs.

Keywords: language impairment, pragmatics, social communication disorder, treatment, randomized controlled
trial

Address correspondence to: Catherine Adams, Human Communication and Deafness Group, Ellen Wilkinson Building, University of
Manchester, Oxford Road, Manchester M13 9PL, UK; email: catherine.adams@manchester.ac.uk
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  c 2012 Royal College of Speech and Language Therapists
DOI: 10.1111/j.1460-6984.2011.00146.x
234 Catherine Adams et al.
What is already known?
Children who have pragmatic and social communication needs are at risk of long term behavioural and social
disadvantage. These children often have additional autism spectrum conditions and/or high-level language
impairments. There are no randomized controlled trials of speech-language intervention for these children.
What this paper adds:
This paper reports evidence of an effect of intensive, specialist supervised speech and language therapy in improving
overall conversational competence and functional social communication skills for school-age children who have
persistent pragmatic and social communication needs. There was no effect of treatment on structural language skills.
The majority of children with pragmatic difficulties also had a history of autism spectrum disorder or pervasive
developmental disorder. Parent and teacher outcomes were important measures in the context of the implementation
of a complex intervention where measurement of pragmatic and social communication skills remain challenging.

Background disorder (SCD)’ may be a more appropriate descriptor.

In proposals for the fifth edition of the Diagnostic and
Pragmatic language impairment (PLI) is present when
Statistical Manual of the American Psychiatric Associa-
children have disproportionate difficulty with the
tion (n.d.), SCD is categorized as a subtype of Language
pragmatic domain of language in relation to relative
Impairment with features that closely match the descrip-
strength in grammar and phonology (Bishop 2000).
tion of PLI provided by Bishop and colleagues in earlier
Pragmatic features of PLI include verbosity, excessive
work. The diagnostic overlaps remain unresolved. In
topic switching, a tendency to dominate verbal interac-
the current study, the term ‘children who have PLI
tions, poor adjustment to listeners’ prior knowledge and
(CwPLI)’ will be used to describe children with a pattern
limited application of inference in naturalistic interac-
of pragmatic and social communication needs similar to
tion (Bishop and Adams 1989, Adams 2001). Symptoms
those described by Bishop (2000) and the SCD profile in
characteristic of specific language impairment (SLI)
DSM-5.
are also present in PLI with some children presenting
The number of children who have significant needs
semantic errors, word-finding difficulties and persistent
in pragmatics and social communication is rising in line
difficulty with receptive language. High-level language
with increased identification of broader ASD conditions
deficits such as poor comprehension of non-literal
(Baird et al. 2006). Botting and Conti-Ramsden (1999)
language and narratives and stories are also evident
identified 22% of children attending UK special-
(Botting and Adams 2005). As a group, children who
ist language units as having PLI. Emerging evidence
have PLI (CwPLI) present considerable heterogeneity
suggests that pragmatic difficulties in the primary school
in social communication and language skills, in both
years may be related to emotional and behaviour difficul-
pattern and severity. The full profile of PLI emerges in
ties, high referral rates to educational psychology services
the early school years as the disparity between structural
(Mackie and Law 2010), longer-than-usual time spent
and social language functioning becomes clear.
in special provision (Botting et al. 1998), and specific
The pragmatic characteristics of CwPLI are similar
difficulty in forming adult relationships in later life
to those reported in high-functioning children who
(Whitehouse et al. 2009).
have autism spectrum disorder (HF-ASD) or pervasive
The need for adequate communication interven-
developmental disorder (PDD1 ) (Landa 2000). PLI and
tions as preventative measures is therefore consider-
HF-ASD may share other abnormalities of communica-
able. Single case studies of CwPLI (Adams 2001) and
tion such as use of stereotyped phrases, intonation and
SCD (Timler et al. 2005, Brinton et al. 2005) have
non-verbal interaction. As with CwPLI, a significant
shown positive effects of intervention on specific aspects
proportion of children who have HF-ASD also have a
of communication such as conversational skills; a case
profile of language impairment similar to SLI (Kjelgaard
study series (Adams et al. 2006) reported a signal of
and Tager-Flusberg 2001). There is consequently
change as a result of intensive speech–language therapy
controversy surrounding the use of PLI as a diagnosis
for six CwPLI. There have been no trials of speech–
distinct from HF-ASD, since the two groups may not
language interventions for CwPLI (Law et al. 2003). The
be distinguishable in terms of social communication
aims of the present study were to examine the effective-
and social interaction deficits. It has been suggested
ness of an intensive manualized social communica-
that CwPLI are typically differentiated from CwHF-
tion speech and language intervention in improving
ASD by the absence of repetitive/restricted behaviours
(1) language skills and (2) observed functional
(Bishop 1998, Leyfer et al. 2008). In addition, since the
pragmatic ability and broader social communication
pattern of communication deficits seen in PLI clearly
of CwPLI within a small-scale randomized controlled
extends beyond the pragmatics domain, there is increas-
trial.
ing consensus that the term ‘social communication
RCT of speech/language therapy for children with pragmatic language impairment
Methods
The two-arm parallel-group randomized controlled trial
was carried out in accordance with the NHS Research
Governance Framework for Health and Social Care
(NHS 2005) and was approved by the Northern
and Yorkshire NHS Research Ethics Committee (REC
No. 07/MRE03/3). All parents gave written informed
consent for their child’s participation. Informed consent
was also gained from the child (where able), their school,
class teacher and learning support assistant (LSA) and
the relevant local authorities.
Participants
The study was powered on the basis of a pilot study
of the intervention (n = 6; Adams et al. 2006). This
demonstrated a clinically significant standardized effect
size for the Clinical Evaluation of Language Fundamen-
tals (CELF-4; Semel et al. 2006) of 0.62 (difference
in means of 3.1 with an SD of 5, based on the sum
of two subtests only). Therefore, target recruitment for
the current study was set at 99 participants, providing
> 80% power to detect a standardized effect size of 0.6
in CELF-4 as the primary outcome.
Speech and language therapists (SLTs) across the
North West of England and South East Scotland referred
to the trial any children on their caseloads aged 6 years
to 10 years 11 months who met the following inclusion
criteria:
• Pragmatic communication problems as observed
by the child’s SLT (including a minimum of two
out of five pragmatic behaviours from a social
communication behaviour checklist (SCBC, see
appendix A).
• Attending mainstream primary education
provision and identified as having Special
Educational Needs (England) or Additional
Support Needs (Scotland).
• English as the primary language of communica-
tion and learning.
• Agreement with the child’s school to accommo-
date intervention and assessment visits.
• No current diagnosis of core autism.
• Currently receiving regular, on-going attention
from SLT services and able to cooperate with direct
intervention.
• No evidence of severe difficulties in emotional
development, behaviour needs, unintelligibility or
hearing.
All referred children were assessed for eligibility and
included in the study if they met the following screening
criteria:
235
• A score in the communication impaired
range (≤ 58) on the General Communication
Composite (GCC) of the Children’s Communica-
tion Checklist—Second Edition (CCC-2; Bishop
2003), a measure functional communication
including pragmatics completed by parents.
• A score ≥ 5th centile on Raven’s Coloured
Progressive Matrices (RCPM; Raven 1979), a
test of non-verbal perceptual/analogical reasoning
skills.
Screening assessments were carried out by a
researcher in the child’s school with one or both parents
present.
The Social Interaction Deviance Composite (SIDC)
of the CCC-2 and the Social Communication Question-
naire Lifetime version (SCQ) (Rutter et al. 2003), a
parent questionnaire which asks about the history of
diagnostic features of autism, were also completed to
provide information on group characteristics but were
not used as part of the inclusion criteria. An SCQ cut-
off score of ≥15 is considered indicative of a history of
PDD, and a cut-off score of ≥22 is considered indicative
of a history of ASD (Berument et al. 1999).2
Randomization, blinding and schedule of
assessments
Following screening and baseline (T1) assessments, a
researcher at the University of Manchester, who was
not independent of the study, randomly assigned each
child to SCIP intervention or treatment-as-usual (TAU)
in a 2:1 ratio, stratified by age group (6;00–8;11 or
9;00–10;11). A 2:1 ratio was used to improve power
for later moderator and mediator exploratory analyses.
Allocation used three possible permuted blocks of size
three:
1: SCIP TAU SCIP
2: SCIP SCIP TAU
3: TAU SCIP SCIP
A new block was selected after every three children in
the same age band.
All assessments (delivery, coding and scoring) were
completed by a research assistant (RA) blind to
treatment allocation; however, families, schools and
those delivering intervention could not be blind to
treatment allocation. At assessment points, children,
parents and schools were reminded that the RA was
blind to treatment allocation and that anything related
to this should not be discussed with them. Question-
naires completed by parents or teachers (CCC-2, PRO
and TRO—see the outcome measures) were returned
236
by post to a researcher who was not involved with
their child’s intervention. Reassessments were carried
out in the child’s school within 2 weeks following
the completion of intervention/TAU (T2) and at
6 months following the completion of interven-
tion/TAU (T3). SCIP intervention began within 4
weeks of pre-intervention (T1) assessment.
Interventions
Participants in the SCIP group ceased their usual
treatment as provided by their local SLT services for
the experimental intervention period. The experimental
treatment was an intensive manualized social communi-
cation intervention with content within a principled
framework aimed at remediation of impairments in
semantics and high-level language skills, pragmatic
difficulties, and social interaction and social cue
interpretation (Adams and Gaile 2012). The research
intervention manual provided procedures for planning
intervention and establishing appropriate goals as well
as all intervention activities. For each child, between
16 and 20 individual face-to-face one hour sessions
of intervention (up to three sessions per week) were
delivered in school over the course of one school
term. Parent/teacher input was solicited throughout the
setting of goals and intervention period. Each child
therefore received an individualized intervention derived
from the manual, but within a specified framework,
as outlined above, so as to ensure that intervention
choices were consistent. Two specialist research speech
and language therapists (RSLT) (one at each of the two
locations) and five specially trained therapy assistants
(ThAs) (England n = 4, Scotland n = 1) delivered the
experimental treatment. Treatment fidelity, measured by
audit of planned intervention sessions versus received
sessions and adherence to written activity procedure
as stated in the manual (both across 10% of sample)
was at ≥ 80% for both measures. A detailed and
precise account of the experimental SCIP interven-
tion, including rationale, the process of manualization,
implementation, intervention components, individu-
alization procedures, required level of practitioner
expertise and treatment fidelity measures, is provided
in Adams et al. (2012).
Children allocated to TAU continued with the
treatment being provided by their local SLT services.
This provision was documented through telephone
liaison with these services (data obtained for 27/29
children). Thirteen of these children (48%) received
Learning Support Assistant (LSA) support provided by
the Education Authority plus SLT contact or contact
from another communication professional. Ten of
these children received direct individual or group-based
intervention. Seventeen SLTs reported general training
Catherine Adams et al.
for LSAs; three had provided training to LSAs aimed
at the management of an individual child. Children in
both arms continued to receive support from their LSAs
(and/or classroom support for learning) throughout the
study.
Post-intervention, children in the SCIP intervention
arm were referred back to their local SLT services for
on-going care. Provision post-intervention to 6-month
follow-up was documented through telephone liaison
with local SLT services obtained for 21/29 children in
the TAU arm and for 47/59 children in the SCIP arm.
Of these children 17 (81%) in the TAU arm, and 30
(63%) in the SCIP arm, received SLT contact. Of these
children, 12 (57% of TAU; 26% of SCIP) children
from each arm were reported to have received direct
individual or group specialist intervention.
After 6-month follow-up (T3) measures, all SLTs of
children allocated to TAU received a manual interven-
tion plan based on what the child would have received
had they been in the SCIP intervention arm.
Outcome measures
The primary outcome measure was predefined as the
CELF-4 (Semel et al. 2006) Core Language Standard
Score (CLSS) as a recognized, reliable and standard-
ized measure of general language ability, which can be
administered blind to treatment allocation. The relevant
subtests were completed with each participant (taking
into account age at that time point) to allow the calcula-
tion of composite core language scores (see appendix
A).
Secondary outcome measures were:
• Targeted Observation of Pragmatics in Children’s
Conversation (TOPICC; Adams et al. 2011): a
semi-structured task that allows for the rating of
overall quality of interaction in conversation (the
same task was used in Bishop and Adams 1989).
Each participant was video recorded discussing a
standard series of three photographs of events with
an RA who used a series of question prompts.
The aim of the task was to obtain a sample of
natural conversation with the child. Three sets of
photographs were used in rotation for each partici-
pant at T1, T2 and T3. Following completion
of all outcome measurement, the video recorded
conversations were rated by a trained, indepen-
dent assessor, blind to treatment allocation, at
the University of Manchester. The assessor was
asked to make a judgement of overall conversa-
tional skills of the child, rating them as improved,
stayed the same or got worse from T1 to T3.
A proportion of T1 and T3 videos (37% of total
available; n = 29, TAU n = 10, SCIP n = 19) were
RCT of speech/language therapy for children with pragmatic language impairment
rated independently by a second assessor also blind
to group status. Raters were asked to consider
the overall impact of any pragmatic behaviours
on the overall quality of interaction. The inter-
rater reliability for the raters was Cohen’s
κ = 0.68, indicating a substantial inter-rater
agreement for overall impression of conversation
change.
• A pragmatics rating scale (CCC-PRAG), derived,
a priori, from the CCC-2. Two highly special-
ist RSLTs provided face validity for this scale by
identifying a list of 18 items which in their view
was closely related to the content of SCIP interven-
tion. An autism-type communication problems
scale (CCC-AUT), consisting of 18 items not
targeted by SCIP intervention directly, was also
identified as a control for predictable bias by
parents in the experimental intervention arm.
Parents completing the CCC-2 would be unaware
of separate PRAG/AUT lists embedded within
it. CCC-PRAG and AUT lists are shown in
appendix A. Scores are sums of rated items,
converted from CCC-2 scoring to a single polarity,
with higher scores indicating greater impairment.
Split-half reliability (internal consistency) of both
CCC-PRAG and CCC-AUT scales were in the
acceptable range (Cronbach’s α for CCC-PRAG
= 0.82; for CCC-AUT α = 0.80). Parents
completed CCC-PRAG/AUT lists at home within
2 weeks following the completion of intervention
(T2) and at 6 months following the completion
of intervention (T3). Completed CCCs were
returned by post to a researcher who was not
involved in the child’s intervention.
• The Expression, Reception and Recall of Narrative
Instrument (ERRNI; Bishop 2004) was used as a
measure of ability to interpret, remember and tell
a pictured narrative. Standardized scores are given
for initial telling of the story (ERRNI-I), story
recall (ERRNI-R) and comprehension (ERRNI-
C). The ERRNI story was alternated at each time
point (therefore the same story was used at T1
and T3).
• Parent-reported outcome (PRO): parents were
asked, via a questionnaire, to state their judgments
about the current status of their child’s Language
Skills (PRO-LS), Social Communication (PRO-
SC), Social Situations (PRO-SS) and Peer
Relationships (PRO-PR) and to rate whether these
have improved, stayed the same or got worse
since pre-intervention (T1). Parents completed
PRO questionnaires at home within 2 weeks
following the completion of intervention (T2)
and at 6 months following the completion
of intervention (T3).
237
• Teacher-reported outcome (TRO): teachers were
asked, via a questionnaire, to state their judgments
about the current status of the child’s classroom
learning skills (TRO-CLS) and to rate whether
these have improved, stayed the same or got worse
since pre-intervention (T1). Teachers completed
TRO questionnaires at school at 6 months
following the completion of intervention (T3)
only.
Statistical analysis
Analysis was by intention to treat3 and was undertaken
after completion of all T3 assessments. For the primary
outcome, and secondary outcomes CCC-2 PRAG/AUT
and ERRNI, analysis was by linear regression with
adjustment for age and the corresponding T1 measure.
Analysis for TOPICC, PRO and TRO was by logistic
regression with similar adjustment for age and the
corresponding T1 measure.
Results
Participants were recruited between April 2007 and
April 2008 in England and between October 2007 and
September 2008 in Scotland. All assessments occurred
within schedule.
Figure 1 shows the trial profile. The study under-
recruited participants (final n = 88) compared with the
target. Fifty-nine participants were randomly assigned
to the SCIP group and 29 participants were randomly
assigned to the TAU group. In the SCIP group
57 participants received intended treatment and were
analysed for the primary outcome. In the TAU group
28 participants received the intended treatment and
were analysed for the primary outcome. Attrition
was therefore 3/88 (3%) for the primary endpoint.
One participant who withdrew from the study during
intervention also withdrew consent for their T1 data to
be used.
Table 1 shows baseline demographic and clinical
characteristics for each group. The groups were well
matched on age, demographics, CELF-4 CLSS and
CCC-2 GCC. Mean Raven’s Progressive Coloured
Matrices mid-point percentile score were slightly higher
in the SCIP than in the TAU group. Scores on the SCQ
showed that 75% of participants scores (76% of SCIP
and 73% of TAU) fell within the range indicative of
the child having PDD or ASD features at some stage in
development.
Primary outcome
The primary outcome measure was CELF-4 CLSS.
Figure 2 shows the spread of CELF-4 CLSS scores at
T1, T2 and T3 for SCIP and TAU groups.
238 Catherine Adams et al.

Figure 1. Trial profile. SCIP, Social Communication Intervention Project.

Figure 2. CELF-4 Core Language Standard Score at T1, T2 and T3 for TAU and SCIP intervention groups. The dotted line is at the CELF-4
CLSS population mean of 100; and the dashed line is at the cut-off between normal range (≥ 80) and language impaired (< 80).
RCT of speech/language therapy for children with pragmatic language impairment 239
Table 1. Baseline demographic and clinical characteristics of each groupc

Whole group SCIP TAU

n = 87 n = 59 n = 28
75 boys, 12 girls 52 boys, 7 girls 23 boys, 5 girls
Mean SD Range Mean SD Range Mean SD Range
Age (months) 100.5 15.0 71–128 100.9 15.1 71–128 99.6 14.8 74–125
NRS ‘ABC1’ demographicsb
Middle to high areaa 30 (34%) 18 (31%) 12 (43%)
Middle to low areaa 49 (56%) 34 (58%) 15 (54%)
Mixed areaa 8 (9%) 7 (12%) 1 (4%)
SCBC (n = 80) 4.4 0.7 3–5 4.4 0.7 3–5 4.4 0.7 3–5
CCC-2 GCC 29.3 12.0 6–57 29.5 12.1 6–57 28.8 12.0 7–56
RCPM percentilee 53.5 28.6 5–96 49.2 28.9 5–96 62.6 26.2 17.5–96
CELF-4 CLSSd 72.6 18.3 40–114 71.3 16.8 40–112 75.3 21.2 40–114
Language impaired CELF-4 61.6 11.2 40–79 62.3 10.5 40–79 59.7 13.2 40–79
CLSSd < 80 (n = 56)
Not language impaired 92.4 9.9 81–114 91.7 8.0 81–112 93.3 12.4 81–114
CELF-4 CLSSd ≥ 80 (n = 31)
CCC-PRAG (n = 86) 34.5 10.0 10–54 34.2 9.9 15–54 35.2 10.3 10–50
CCC-AUT 28.1 10.2 6–49 27.9 10.6 8–49 28.4 9.6 6–44
ERRNI-Id 90.9 17.4 64–135 90.3 17.4 65–135 92.1 17.6 64–122
ERRNI-R d 86.4 18.2 64–136 85.8 17.2 64–131 87.7 20.3 64–136
ERRNI-Cd 87.7 16.0 64–125 87.2 16.6 64–125 88.7 14.8 64–115
SCQ (n = 84)∗ 20.3 7.9 2–37 20.3 7.7 3–37 20.2 8.3 2–33
Non-ASD SCQ ≤ 14a 21 (25%) 14 (24%) 7 (27%)
PDD-NOS SCQ 15–22a 23 (27%) 17 (29%) 6 (23%)
ASD SCQ ≥ 22a 40 (48%) 27 (47%) 13 (50%)
Notes: a n (%).
b
Area based on postcode. Middle to high areas include ≥ C2 only; middle to low areas include ≤ C1 only; and mixed areas included a range from A/B to D/E.
c
n = 87 as one child withdrew without giving permission to use the data.
d
Standard scores have a population mean = 100.
e
RCPM percentile ranges transformed into percentile midpoints, e.g. 5th–10th percentile becomes 7.5th percentile
∗
SCQ scores ≥ 15 are considered indicative of PDD-NOS; and scores ≥ 22 are considered indicative of ASD.
NRS, National Readership Survey (NRS Ltd); SCBC, Social Communication Behaviour Checklist; CCC-2 GCC, Children’s Communication Checklist-2 General Communication
Composite; RCPM, Ravens Coloured Progressive Matrices; CELF-4 CLSS, Clinical Evaluation of Language Fundamentals Core Language Standard Score; CCC-PRAG, Pragmatics
rating scale; CCC-AUT, Autism-Communication Rating Scale; ERRNI-I/R/C, Expression, Reception and Recall of Narrative Instrument Initial Telling/Story Recall/Comprehension
Standard Score; SCQ, Social Communication Questionnaire.

Using linear regression, comparison was made
between the TAU and SCIP groups on the CELF-4
CLSS at T2 and T3 with adjustment for age and the
CELF-4 CLSS at T1. No significant treatment effect
was found at T2 (p = 0.78) or T3 (p = 0.87). The
estimated group difference at T2 was 0.5 (95% CI =
–3.1 to 4.1) and at T3 was 0.3 (95% CI = –3.7 to 4.4).
Given that a large proportion (36%) of participants
were found to have CELF-4 CLSS well within the
normal range (CELF-4 CLSS > 80) at baseline, a further
exploratory comparison was made for the subgroup of
children who scored in the low ability/language impaired
range (CELF-4 CLSS < 80) at baseline. Conclusions
were similar: the estimated group differences (95% CI)
at T2 and T3 were 3.9 (–1.3 to 8.9) and 1.4 (–4.8 to
7.6) respectively.
Secondary outcomes
Table 2 shows the results of secondary outcomes at T2.
No significant treatment effects were found for CCC-
PRAG/AUT or ERRNI at T2. However, parent ratings
(PRO) showed significant differences by treatment
group in favour of SCIP at T2.
Table 3 shows the results of secondary outcomes
at T3. TOPICC, CCC-PRAG, PRO-SC and PRO-
SS, and TRO-CLS showed significant differences by
treatment group in favour of SCIP at T3. However,
no significant treatment effects were found for CCC-
AUT, ERRNI, PRO-LS or PRO-PR at T3. Note that
for PRO-PR numbers in the control group were too
small for analysis by logistic regression.
Discussion
This is the first randomized controlled trial investigating
the effectiveness of intervention for children who have
PLI. The first aim was to establish the effects of the
SCIP intervention compared with TAU on standardized
language assessment.
The primary outcome, a standardized measure of
overall language performance (CELF-4 CLSS), did
240 Catherine Adams et al.
Table 2. Secondary outcomes at Time 2

SCIP TAU Effecta

n Mean (SD) n Mean (SD) Mean difference (95% CI) p
CCC-PRAG 49 30.9 (10.2) 21 29.4 (11.4) 0.7 (–3.3 to 4.6) 0.74
CCC-AUT 50 26.3 (10.8) 21 23.3 (8.9) 1.6 (–2.1 to 5.3) 0.39
ERRNI-I 57 90.9 (17.8) 28 90.9 (17.3) 0.31 (–6.9 to 7.5) 0.93
ERRNI-R 57 91.2 (20.2) 28 88.3 (21.2) 3.7 (–4.7 to 12) 0.38
ERRNI-C 57 89.1 (13.9) 28 87.1 (12.9) 2.4 (–3.3 to 8.1) 0.41
n (%) improved n (%) improved Odds ratio (95% CI)
PRO-LS 50 38 (76) 19 4 (21.1) 11.9 (3.3–42.7) < 0.001∗∗
PRO-SC 48 35 (72.9) 20 7 (35) 5 (1.6–15.2) 0.005∗∗
PRO-SS 47 27 (57.4) 21 3 (14.3) 8.7 (2.2–34.2) 0.002∗∗
PRO-PR b 40 20 (48.8) 18 1 (5.6)
Notes: a Mean difference by linear regression or odds ratio by logistic regression.
b
Numbers improved in the control group too small to compute odds ratio.
∗∗
p < 0.01.
Abbreviations are as given in table 1, except for PRO-LS/SC/SS/PR, Parent Reported Outcome—Language Skills/Social Communication/Behaviour in Social Situations/Peer Relation-
ships.

not show a significant intervention effect for SCIP
compared with TAU, nor did a secondary standard-
ized measure of narrative ability (ERRNI). The identifi-
cation of a single, predefined standardized outcome
measure, which was sensitive enough to capture change
in pragmatic impairment, although highly desirable,
was not easily achievable for this complex group. Over
one-third of participants recruited were found to be
performing well within the normal range on CELF-4
CLSS (and ERRNI) at pre-intervention assessment.
A further exploratory comparison was therefore made
for the subgroup of children who scored in the low
ability/language impaired range (CELF-4 CLSS < 80)
at baseline. This comparison showed a trend in favour
of intervention, but had insufficient power to detect
plausible differences between groups. Inspection of the
standard score increments and confidence intervals on
CELF-4 CLSS also indicate that very large changes in
raw scores (larger than those considered clinically signifi-
cant) would be required to show shift in standard scores.
Despite CELF-4 CLSS being a recognized, reliable
and objective test of general language function, some
CwPLI in this study had functional difficulties with
language processing that were evident to teachers and
parents but which were not detected by standardized
language tests. Further, some CwPLI functioned in the
normal range across all language tasks and did not
present concern to teachers or parents, except in the
pragmatics and social communication domain. Further
characterization of the PLI ‘population’ may therefore be

Table 3. Secondary outcomes at Time 3

SCIP TAU Effecta

n Mean (SD) n Mean (SD) Mean difference (95% CI) p
CCC-PRAG 39 27.9 (12.9) 16 33.5 (9.0) 5.5 (0.04–10.9) 0.049∗
CCC-AUT 41 24.3 (11.4) 16 24.1 (9.6) 0.13 (–4.8 to 5.1) 0.96
ERRNI-I 57 97.2 (14.8) 28 100.8 (13.8) 3.3 (–2.5 to 9.1) 0.27
ERRNI-R 57 93.7 (20.9) 28 93.5 (23.2) 0.58 (–8.7 to 9.9) 0.90
ERRNI-C 57 91.6 (14.5) 28 93.4 (15.5) 1.4 (–4.7 to 7.5) 0.64
n (%) improved n (%) improved Odds ratio (95% CI)
TOPICC 51 22 (43.1) 27 5 (18.5) 0.3 (0.1–0.9) 0.04∗
PRO-LS 38 26 (68.4) 16 7 (43.8) 2.9 (0.9–9.9) 0.09
PRO-SC 38 28 (73.7) 16 4 (25.0) 8.0 (2.1–31.1) 0.003∗∗
PRO-SS 38 24 (63.2) 15 3 (20.0) 7.4 (1.7–31.8) 0.007∗∗
PRO-PR 38 24 (63.2) 14 7 (50.0) 1.6 (0.5–5.7) 0.46
TRO-CLS 40 30 (75.0) 18 8 (44.4) 3.7 (1.2–12.1) 0.03∗
Notes: a Mean difference by linear regression or odds ratio by logistic regression.
∗
p < 0.05; ∗∗ p < 0.01.
Abbreviations are as given in tables 1 and 2, except TRO-CLS, Teacher Reported Outcome—Classroom Learning Skills.
RCT of speech/language therapy for children with pragmatic language impairment
required to understand the true nature and occurrence
of underlying language impairments as well as develop-
ment of sensitive, valid and objective measures of high
level language outcomes. The content of CELF-4 CLSS
was also ultimately relatively far removed from the
intervention goals in SCIP which emerged for individu-
als over time. These tended to be at the levels of activity
and participation, reflecting the priorities of parents
and teachers whose input was solicited throughout the
setting of goals and intervention period.
The second aim was to explore any notable effects
of the SCIP intervention compared with TAU, on
observed functional pragmatic ability and broader social
communication.
Significant intervention effects were found for SCIP
intervention compared with TAU for overall conversa-
tional quality (TOPICC) between baseline and 6-
month follow-up. This finding is important given that
it was achieved using blind rater perceptions. It is
carefully noted, however, that approximately half of
the intervention group were rated as not improved on
this measure, indicating that only some CwPLI are
likely to be able to adapt conversational style with a
short period of intervention. It would be important to
identify, in further research, variables associated with
potential for change in order to adopt differential
management strategies. TOPICC ratings were based on
blind perceptions of change between baseline and 6-
month follow-up suggesting the intervention effect is
maintained well beyond the end of intensive therapy for
these children who did show change.
Significant intervention effects were also found for
SCIP intervention compared with TAU for non-blind
parent-reported social communication, social behaviour
and language skills immediately following intervention.
These effects were maintained at 6-month follow-up for
social communication and behaviour in social situations.
Significant intervention effects were also found for non-
blind teacher ratings of classroom learning skills at 6-
month follow-up (measured at T3 only).
Non-blind parent-reported pragmatic functioning
(CCC-PRAG) showed a significant intervention effect
compared with TAU at 6-month follow-up, but not
immediately following intervention. It might therefore
be that skills learned in an intensive period of therapy
take time to be consolidated in broader contexts, which
would contribute to a possible ‘sleeper effect’ where the
effects of treatment may be undetectable on immediate
post-test but become apparent on later testing. CCC-
PRAG was composed of a diverse list of pragmatic
skills, not all of which could have been addressed in any
single individual’s intervention. It was not unexpected
therefore that this finding just achieved significance.
It is important to note that between-condition
effects on non-blind parent and teacher-reported
241
measures were subject to bias and therefore need to
be interpreted with great caution. In this study we
aimed to mitigate bias by extracting two sets of items,
CCC-PRAG (behaviours targeted in the intervention)
and CCC-AUT (not targeted in the intervention) from
CCC-2 assessments. The hypothesis that intervention
which targeted pragmatics should show an effect on
CCC-PRAG only was confirmed. Parent report was able
to differentiate effects for these two aspects of communi-
cation.
Differential effects across categories were also
demonstrated within Parent Reported Outcomes, where
findings were not universally in favour of interven-
tion across individual items. Although careful attention
was given to the method of reporting to attempt
to control halo effects, it is possible that parents in
the intervention group were biased to report positive
changes in aspects of intervention which they perceived
as central to therapy, but, in practice, intervention
contained multiple integrated components and these
were not explicitly labelled by therapists. Further,
exploration of outcome measures indicates that there
is convergence in the types of functional communica-
tion changes observed by parents across measures (CCC-
PRAG/PRO) and good agreement between parent
CCC raters and blind TOPICC raters (Adams et al.
2011).
Delivering a complex individualized speech–
language intervention to a relatively heterogeneous
population, in the context of all the variables of real-
life school environments was exceptionally challeng-
ing and there are several potential limitations and
possibilities for bias which have to be controlled. The
TAU group received less direct specialist intervention
than participants receiving SCIP (Adams et al. 2012)
making it difficult to attribute intervention effects to the
specific content of SCIP rather than increased specialist
attention. However, the TAU group continued to receive
SLT support via LSAs in a training/consultancy model
which is widely used in UK mainstream SLT services.
Thus, this was a fair comparison of the experimental
treatment to the care that would have been received
were the trial not to have taken place and therefore has
ecological validity.
In this study, the developer of the SCIP intervention
and the TOPICC outcome measure is also the evaluator
of the intervention in this trial. As such, a potential for
systematic bias related to conflict of interest may exist
(Petrosino and Soydan 2005). However, the trial was
rigorous with respect to blinding and pre-definition of
outcome measures.
These findings highlight important implications for
future studies of interventions for complex developmen-
tal constructs such as PLI and SCD. This complexity
means that it is unlikely that there will be uniform
242
outcome effects across participants due to differential
profiles of impairment and rates of development (Koenig
et al. 2009). Obtaining a balance in outcome measures
between sensitivity to change in performance increments
(where potential measureable outcomes are many) and
meaningful functional communication change is a real
challenge in intervention trials such as these. The
TOPICC method of using blind rater perception of
overall conversational quality holds promise as a way of
capturing change across a complex population present-
ing with wide ranging impairments that impact on the
quality of conversation in different ways. However, there
is a need to develop measures which are specific and
sensitive to the perceived needs of the children from
the service users’ perspective too. Therefore, parent or
teacher-reported outcomes may ultimately be a more
powerful primary outcome measure in a study such as
this.
Conclusions and clinical implications
The overall conclusions are that it is likely that
the intervention provided in SCIP is effective at
improving overall conversational quality (but not
structural language skills) in 6–11 year olds who have
significant pragmatic and social communication needs
compared with TAU.
SCIP is perceived by parents and teachers as effective
at improving some functional pragmatic and social
communication skills at home, and classroom learning
skills, for these children.
The implications are that, with carefully targeted
specialist intervention, there is potential for some change
in some school-aged children who have persistent
pragmatic and social communication needs, even with a
brief period of speech and language therapy. The amount
of therapy offered was constrained by the experimen-
tal model; in reality, some children may require longer
periods of intervention to consolidate gains made in
the intensive period of therapy. Changes in individual
children varied widely and a further stage of enquiry
would be to investigate factors which contribute to this
finding.
These findings may provide some support for the
conclusions of a recently reported trial of interven-
tion for children with SLI (McCartney et al. 2011),
which concluded that the effects of a specialist interven-
tion can be lost whilst attempting to embed it within
a consultancy training model. In the present study’s
TAU condition, children received less direct interven-
tion but continued to receive SLT support from LSAs via
a consultancy model. Many children had received this
support for a long period of time and continued to do
so. In the SCIP condition, direct therapy was intensively
provided using a model of specialist SLT provision
supported by specially trained assistants (with additional
Catherine Adams et al.
indirect support). In future work it will be important to
include estimates of cost-effectiveness and the resources
required to support alternative models of delivery. It
would be essential to look at the balance between a more
intensive, mixed direct/indirect, specialist-led provision
which has the potential to produce outcomes desired by
service users and the more indirect SLT models which
are generally provided over longer periods and whose
potential for achieving desired outcomes is unknown.
Although resources prevented the use of gold
standard autism diagnostic procedures such as the
Autism Diagnostic Observation Schedule (ADOS; Lord
et al. 2000), there is an indication that our PLI group
showed a substantial overlap with children with HF-
ASD/PDD and that SCIP may therefore also be a
relevant intervention in addressing social communi-
cation skills in this group. We emphasize though
that SCIP intervention is aimed at optimizing social
communication, it does not aim to ‘cure’ communica-
tion impairments or change autistic symptomatology.
The findings are suggestive of changes in children’s
communication skills which are perceived as meaning-
ful to those living and working with the children daily.
Such indicators are now seen as central to the aspiration
of delivering services which are designed around the
family (Department for Children, Schools and Families
(DCSF) 2008).
Acknowledgements
This study was funded by the Nuffield Foundation (Grant Reference:
EDU/32953) and sponsored by the University of Manchester.
The authors gratefully thank the participating children, parents,
schools, and referring speech and language therapy services in the
North West of England and in the South East Scotland area. They
acknowledge the cooperation of the Centre for Integrated Healthcare
Research, Queen Margaret University, Edinburgh; and the support
and guidance from their study advisory committee (Sue Roulstone,
Bonnie Brinton, Martin Fujiki and Geoff Lindsay). Declaration of
interest: The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the paper. The
intervention described in this paper is currently in preparation for
publication in book form by two of the authors (Adams and Gaile).
Notes
1. The term ‘PDD’ is likely to be subsumed under ASD in DSM-5;
therefore, it will not be used from this point. Note that it does
appear in the SCQ assessment used in this study. The proportion
of children with historical ASD and PDD on this assessment will
be interpreted as all falling into a broader ASD definition (see
the Results).
2. SCQ Lifetime scores are based on parent report of autism features
which have occurred in the child’s lifetime; it is probable that the
behavioural and social profile of the child in the current study
will have changed to some degree over time, so no definitive
diagnosis of current autism functioning can be derived.
3. Outcome data for all randomized participants were included in
analysis where available.
RCT of speech/language therapy for children with pragmatic language impairment
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244 Catherine Adams et al.
Appendix A
Table A1. Social Communication Behaviour Checklist (SCBC)
used for recruitment purposes only

Yes/no
The child has trouble understanding and interpreting the social context and friendship, e.g. social roles, emotions
The child has trouble understanding and/or using non-verbal aspects of communication, e.g. facial expression, intonation
The child has trouble with aspects of conversation, e.g. beginning and ending, taking turns, giving relevant and sufficient information
The child makes bizarre, tangential or inappropriate comments
The child has difficulty using and understanding non-literal language

Table A2. CELF-4 Core Language Scale subtests by age

Ages 5–8;11 Ages 9–12

Concepts and following directions Concepts and following directions
Word structure Recalling sentences
Recalling sentences Formulating sentences
Formulating sentences Word classes 2 (receptive and expressive)

Table A3. Children’s Communication Checklist-2 Pragmatics

(PRAG) and Autism-communication (AUT) subscales (derived
from Bishop 2003)

(a) CCC-2 PRAG

1 Gets confused when a word used with a different meaning
2 Includes over-precise information
3 It’s hard to make sense of what he is saying even though the words are clear
4 It’s difficult to stop him or her from talking
5 Tells people things they know already
6 Gets the sequence of events muddled up when trying to tell a story
7 Doesn’t explain what he is talking about to someone who doesn’t share their experiences
8 Can be hard to tell if she is talking about something real or make believe
9 Talks to people too readily
10 Takes in just one or two words in a sentence and so misinterprets
11 Moves the conversation to a favourite topic, even if others not interested
12 Talks repetitively about things that no one is interested in
13 Uses terms like ‘he’ or ‘it’ without making it clear what s/he is talking about
14a Talks to others about their interests rather than his own
15 When answering a question, provides enough information without being over precise
16 Realises the need to be polite
17 Talks about his friends, shows an interest in what they say and do
18 Keeps quiet in situations where someone else is trying to talk or concentrate
19 You can have an enjoyable, interesting conversation with her
20 Explains a past event clearly
Note: a Reversed polarity from this point.