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Pre‐pragmatic language use in toddlerhood: Developmental antecedents, aetiological factors, and associations to autism

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Background Pragmatic language is key for adaptive communication, but often compromised in neurodevelopmental conditions such as autism spectrum disorder (ASD). Decontextualized language—to talk about events and things beyond here and now—develops early in childhood and can be seen as a pre‐pragmatic ability. Little is known about the factors that contribute to decontextualized language use in toddlers and whether these are different from factors contributing to general language development. Methods We studied longitudinal associations between parent‐rated core language and non‐verbal socio‐communicative abilities at 14 months of age, and decontextualized language use at 24 months of age in children with typical and elevated likelihood of ASD (total N = 303). Using twin modelling, we also investigated genetic and environmental contributions on decontextualized language and grammar use in two‐year‐old twin pairs (total N = 374). Results Core language ability was a strong predictor of later decontextualized language use in both children with and without an elevated likelihood of ASD. In contrast, social communication was only a significant predictor of decontextualized language use for children with low levels of core language. This pattern was specific to decontextualized language, and not replicated in prediction of concurrent grammatical ability. Further, there was a large genetic influence on decontextualized language at 2 years of age, which mostly overlapped with the genetic influences on grammatical ability. Shared environment influences were significant for grammatical ability, but not found on decontextualized language. In children with an elevated likelihood of ASD, decontextualized language use was negatively associated with autistic symptoms. Conclusions This study suggests that decontextualized language is developmentally associated with, yet dissociable from, more general language development measured as grammatical ability. Already at 2 years of age, parental ratings of decontextualized language is associated to clinician‐rated symptoms of ASD.
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Received: 8 August 2022
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Accepted: 18 December 2022
DOI: 10.1002/jcv2.12135
ORIGINAL ARTICLE
Prepragmatic language use in toddlerhood: Developmental
antecedents, aetiological factors, and associations to
autism
Maja Rudling
1
|Ana Maria Portugal
1,2
|Sven Bölte
2,3
|Terje FalckYtter
1,2,4
1
Department of Psychology, Development and
Neurodiversity Lab, Uppsala University,
Uppsala, Sweden
2
Department of Women's and Children's
Health, Center of Neurodevelopmental
Disorders (KIND), Centre for Psychiatry
Research, Karolinska Institutet, Stockholm,
Sweden
3
Curtin Autism Research Group, School of
Allied Health, Curtin University, Perth,
Western Australia, Australia
4
Swedish Collegium for Advanced Study,
Uppsala, Sweden
Correspondence
Maja Rudling, Uppsala University, Box 1225,
751 42 Uppsala, Sweden.
Email: maja.rudling@psyk.uu.se
Funding information
European Commission, Grant/Award
Numbers: H2020 project CANDY, 847818;
Innovative Medicines Initiative 2 Joint
Undertaking, Grant/Award Number: 777394;
Knut and Alice Wallenberg Foundation;
Riksbankens Jubileumsfond and the Swedish
Collegium for Advanced Study, Grant/Award
Numbers: NHS141802, 1; Swedish Research
Council, Grant/Award Number: 201806232
Abstract
Background: Pragmatic language is key for adaptive communication, but often
compromised in neurodevelopmental conditions such as autism spectrum disorder
(ASD). Decontextualized language—to talk about events and things beyond here and
now—develops early in childhood and can be seen as a prepragmatic ability. Little is
known about the factors that contribute to decontextualized language use in tod-
dlers and whether these are different from factors contributing to general language
development.
Methods: We studied longitudinal associations between parentrated core language
and nonverbal sociocommunicative abilities at 14 months of age, and decontex-
tualized language use at 24 months of age in children with typical and elevated
likelihood of ASD (total N=303). Using twin modelling, we also investigated genetic
and environmental contributions on decontextualized language and grammar use in
twoyearold twin pairs (total N=374).
Results: Core language ability was a strong predictor of later decontextualized
language use in both children with and without an elevated likelihood of ASD. In
contrast, social communication was only a significant predictor of decontextualized
language use for children with low levels of core language. This pattern was specific
to decontextualized language, and not replicated in prediction of concurrent
grammatical ability. Further, there was a large genetic influence on decontextual-
ized language at 2 years of age, which mostly overlapped with the genetic influences
on grammatical ability. Shared environment influences were significant for gram-
matical ability, but not found on decontextualized language. In children with an
elevated likelihood of ASD, decontextualized language use was negatively associ-
ated with autistic symptoms.
Conclusions: This study suggests that decontextualized language is developmentally
associated with, yet dissociable from, more general language development
measured as grammatical ability. Already at 2 years of age, parental ratings of
decontextualized language is associated to clinicianrated symptoms of ASD.
KEYWORDS
autism spectrum disorder, decontextualized language, language development, pragmatic
language, social communication, twin analysis
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, pro-
vided the original work is properly cited.
© 2023 The Authors. JCPP Advances published by John Wiley & Sons Ltdon behalf of Association for Child and Adolescent Mental Health.
JCPP Advances. 2023;3:e12135. wileyonlinelibrary.com/journal/jcv2
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https://doi.org/10.1002/jcv2.12135
INTRODUCTION
To use language in a socially adaptive way requires a range of abili-
ties. Core language, here defined as vocabulary, phonology, and
grammar, is required to put thoughts into words and to linguistically
convey meaning. Sociocommunicative abilities are utilized to inter-
pret and adapt to everchanging social situations. Conceptually in
between core language and social communication is pragmatic ability.
This, we use to adapt language to communicate effectively with
others, taking others' perspectives into account to form coherent and
meaningful utterances given the conversational context. The influ-
ential Relevance Theory (Carston, 2002; A. C. Wilson & Bishop, 2019;
D. Wilson & Sperber, 2002) proposes that while we use both core
language and pragmatic abilities when inferring meaning from often
ambiguous linguistic information, these two aspects are still clearly
dissociable. In this theory, pragmatics is seen as part of domain
general processes that are not only separable from the decoding
module of core language, but rather functions to infer meaning from
communicative information more generally. However, all tests of
pragmatic ability put demands on core language ability, and some-
times viceversa, making the two aspects hard to empirically differ-
entiate. Potentially as a consequence, core language and pragmatics
scores generally correlate strongly and are closely associated
developmentally, and empirical support for a clear dissociation be-
tween core and pragmatic language has been inconclusive
(Happe, 1993; Matthews et al., 2018; A. C. Wilson & Bishop, 2019,
2021a). According to an account put forward by Wilson and
Bishop (2019,2021a) core and pragmatic language abilities may be
most closely interrelated in early language development, becoming
subsequently more separate as linguistic and social capabilities in-
crease. To advance our understanding of the development of prag-
matic ability, an important question is therefore how core and
pragmatic language are longitudinally and aetiologically associated in
early development. This question has been difficult to study, partly
due to the difficulty in measuring pragmatics in a valid way, especially
in early language development.
In autism spectrum disorder (ASD), a neurodevelopmental con-
dition characterized by alterations of social communication and be-
haviours (DSM5; American Psychiatric Association, 2013), pragmatic
language difficulties are practically universal (Baird & Norbury, 2016;
M. Miller et al., 2015; A. C. Wilson & Bishop, 2021b). In contrast, core
language abilities vary greatly between individuals with the condition
(Kjelgaard & Tagerflusberg, 2001). Despite the high prevalence of
pragmatic language difficulties in ASD, the development of pragmatic
and core language in association to symptoms of ASD is not well
understood. Such knowledge could be crucial for developing early
directed interventions to better support autistic children and their
families.
It has been argued that, moving forward, the study of pragmatic
development should avoid global measures of pragmatics and instead
focus on specific pragmatic abilities (Matthews et al., 2018). One such
pragmatic ability is the use of decontextualized language; to talk
about perceptually absent referents, such as past or future events, or
objects and ideas that are not present (Rowe, 2013; Ucelli, 2009). To
do this proficiently, one must linguistically provide the context that is
needed for correct references. Cognitively, this requires an
understanding of the conversational common ground; socially, it re-
quires sensitivity and adaptation to the listeners understanding and
knowledge; and linguistically, it requires a proficient enough syntactic
and semantic ability to convey references clearly. Typically, children
start using decontextualized language around 1.5–2 years of age
(Berglund & Eriksson, 2000b; P. J. Miller & Sperry, 1988;
Ucelli, 2009), initially relying on interpretation and coconstruction
from conversational partners (Uccelli et al., 2019). Arguably, this
makes decontextualized language an early emerging prepragmatic
ability, potentially suitable for studies of pragmatic development in
young ages. To our knowledge, only one study has focussed on how
core language and social communication are associated with the
development of decontextualized language use. Miniscalco and col-
leagues studied 36 children with an ASD diagnosis, and found that
imitation at three years of age predicted improvement in decontex-
tualized language use from ages three to four years, whereas core
language did not (Miniscalco et al., 2014). However, no comparison
group was used, so we cannot conclude if these associations were
specific for children with ASD.
In the present study, we had two preregistered research ques-
tions. First, we studied how early core language and nonlinguistic
sociocommunicative abilities at 14 months were associated with
decontextualized language use at 24 months of age in children in the
general population. Based on the notion of codependency between
social and linguistic abilities early in development (A. C. Wilson &
Bishop, 2019,2021a) we expected both core language and social
communication in infancy to be important for decontextualized lan-
guage use in toddlerhood, potentially interacting with each other.
Second, we studied how early decontextualized language use was
associated to autistic traits in toddlerhood and with likelihood of ASD
due to having a firstdegree family member with the condition.
Because of the link between pragmatic language and autism later in
Key points
Pragmatic language is important for everyday life and
difficulties with pragmatic language are associated with
ASD.
Despite its theoretical and practical relevance, little is
known about the early development of pragmatic
language.
We showed that core language at 14 months predicted
decontextualized language use at 24 months, a potential
early measure of pragmatics, and that it moderated the
association between social communication and decon-
textualized language.
Already at 2 years of age, parentrated decontextualized
language use was associated with clinicianrated autistic
symptoms and with likelihood of ASD, beyond core lan-
guage ability and nonverbal general developmental
level.
These results advance our understanding of early prag-
matic language use in both typical and autistic develop-
ment, with potential implication for directed intervention.
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RUDLING
ET AL.
development, we expected to find an association between decon-
textualized language use and autism. To investigate these two
questions we utilized two longitudinal study samples: Babytwins
Study Sweden (BATSS; FalckYtter et al., 2021) and Early Autism and
ADHD Sweden (EASE; FalckYtter et al., 2018). The BATSS sample
consisted of samesex twin pairs. The EASE sample consisted of
children with a firstdegree relative with an ASD diagnosis, and a
comparison group of children with no firstdegree relatives with the
diagnosis, constituting the elevatedlikelihood group and the typical
likelihood group respectively. In accordance with the analysis plan,
developmental antecedents were studied in children from the BATSS
and the typicallikelihood group from EASE, representing the general
population. Associations to autism, here measured as autistic traits
and likelihood group membership, were studied in children from the
EASE sample.
Two secondary analyses were later added to investigate the
theoretical dissociation between core and pragmatic language in
the general population. Here we did not include the elevated
likelihood group from EASE, as we had no specific hypotheses of
the association between core and pragmatic language being
different for children with elevated likelihood of later ASD diag-
nosis. First, we tested if the longitudinal association between core
language and social communication was specific to decontextual-
ized language use or generalised also to concurrent core language,
measured as grammatical language use at 2 years age. Second,
utilizing the twin sample, we investigated how aetiological factors
were associated with decontextualized language use and early
grammatical ability.
METHODS
Participants
Participants from the two studies (BATSS and EASE) were included if
they had data at both timepoints (14 and 24 months of age). General
exclusion criteria for the BATSS and EASE studies were diagnosis of
epilepsy or history of fits/convulsions; any known genetic syndrome
clearly related to ASD; any known significant, uncorrected vision or
hearing impairment; any known significant developmental or medical
condition likely to affect brain development; premature birth (prior
to week 34 for BATSS, and week 36 for EASE).
The BATSS sample
The children in the BATSS sample were recruited from the greater
Stockholm area, via the national population registry in Sweden.
Eleven children were excluded from the main, analyses and 19 from
the twin analysis due to not fulfiling inclusion criteria (seizures at the
time of birth, meningitis early in life, and twintotwin transfusion
syndrome). Because measures from twins are not independent, only
one, randomly chosen twin from each pair was included in the main
analyses (N=178, 49.4% boys). In the twin analysis, both cotwins
were included (N=374, 49.2% boys). The zygosity of twin pairs
was estimated based on DNA in saliva (monozygotic twins N=209,
dizygotic twins N=165).
The EASE sample
The EASE sample (N=125, 52.8% boys) was divided into two groups
depending on whether the children had a firstdegree relative with
ASD or not. The recurrence rate of ASD in younger siblings of chil-
dren with the condition is 20% (Ozonoff et al., 2011), making the
likelihood of ASD elevated in families with an autistic member
compared to the general population. Children in the elevated likelihood
group (N=97, 53.6% boys) were recruited via the EASE project's
website, advertisement, and clinical units. They had a sibling or
parent with an ASD diagnosis, which was confirmed through clinical
interviews and medical records. Children without a firstdegree
relative with ASD were considered to have typical likelihood of ASD,
and these children (EASE typical likelihood group; N=28, 50.0%
boys) were recruited from birth records and advertisements.
Combined typical likelihood group
Because none of the included variables, except for chronological age
(see below), differed significantly between the BATSS (onetwin)
sample and the typicallikelihood group of the EASE sample (even
after correcting for chronological age), we combined these two
groups of children to form the combined typical likelihood group
(N=206, 49.5% boys), representing the general population.
Measures
Swedish early communicative development inventory
The Swedish Early Communicative Development Inventory (SECDI;
Berglund & Eriksson, 2000a; Eriksson & Berglund, 1999) is the
Swedish version of the MacarthurBates Communicative Develop-
ment Inventory (CDI; Fenson et al., 1994). It is a questionnaire
wherein parents rate early linguistic and social behaviours.
The two main independent variables were extracted from the
SECDI Words and Gestures form and collected when the participants
were 14 months old. The Total Gesture Score was used as a mea-
sure of social communication. It consists of 63 1point items on five
subscales: First Communicative Gestures, Games and Routines, Ac-
tions With Objects, Pretending To Be a Parent, and Imitating Other
Adult Actions. The Core Language Composite was calculated by
combining zscores of the scales Comprehension of Sentences and
the Comprehension Score to get a broader measure of core language
that included both grammar and vocabulary. The zscores were
extracted from the group means separately for the combined typical
likelihood group and the EASE elevated likelihood group when this
measure was to be used for the groups separately. In the analyses of
associations with group membership (the EASE elevated likelihood
and typical likelihood groups) the zscores were based on the means
of these two groups combined. Comprehension of Sentences consists
of 27 common, short phrases that the parent's mark if their child
understands (e.g. “clap your hands”). The Comprehension Score
measures receptive vocabulary; parents mark which words in a
checklist of 370 common words that their child understands. These
two measures correlated strongly in our sample, both for the
PREPRAGMATIC LANGUAGE USE IN TODDLERHOOD
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combined typical likelihood group (r=0.76, p<0.001) and the
elevated likelihood group (r=0.81, p<0.001).
The main dependent measure, used as a measure of decontex-
tualized language, was the Pragmatics Scale (“How children use lan-
guage”) of the SECDI Words and Sentences form, collected when
participants were 24 months old. The last item (whether the child
make up names for toys) was excluded, as this item generally decreases
the internal consistency of the scale and was excluded from the
norming process of the SECDI (Berglund & Eriksson, 2000a). Thus, the
scale contained five 0to2scaled items: (1) Does your child ever talk
about things that have happened before? (2) Does your child ever talk
about things that are going to happen in the future? (3) Does your child
ever talk about things that are missing, for example, if a doll has dis-
appeared or about people that are not present? (4) Does your child
understand if you ask about something that is not immediately present,
that is, if you ask your child to get a toy from another room (5) Does it
ever happen that your child picks up or points towards another per-
son's object and speak the name of that person?
The Grammar Scale, of the SECDI Words and Sentences form,
consists of six items (maximum 12 points), with questions about the
child's use of morphological markers of the possessive, singular,
plural, past tense, and supine forms (a common marker of the past
tense in Swedish).
ADOS2
The ADOS2 (Lord et al., 2012) is an instrument used to elicit ASD
associated behaviours in semistructured play situations. In the EASE
sample, children were evaluated with the ADOS2 at 24 months of
age. Two different modules were used depending on the develop-
mental level of the child: The toddler module and module 2. To compare
scores across modules, we used the calibrated severity scores.
Background variables
Background information was collected when the children were
5 months. Socioeconomic status (SES) was defined as the highest
educational level on a 4point scale (averaged between parents in the
cases where information on both parents was available; all but 48
participants). The information of whether at least one parent spoke
Swedish as their first language was missing from 48 participants in
the EASE study, due to studyprotocol changes. Chronological age
was defined as the child's age at the time when the SECDI forms
were filled in electronically. Within the EASE sample, for 23 partici-
pants at the 14months timepoint and 11 participants at the 24
months timepoint, the date of registering the SECDI form was
incorrect in the database and was therefore changed to that of the
corresponding lab visit.
Analyses
The analysis plan was preregistered in the Open Science Framework
(DOI 10.17605/OSF.IO/F7GV8) before any analysis was performed.
Hypotheses related to developmental antecedents and links to ASD
symptoms and likelihood were preregistered, while the specificity
and twin analyses were not. Analyses were performed using SPSS
version 27 (IBM Corp., Armonk, N.Y., USA), and the PROCESS tool
(Hayes, 2013). Significance tests were all twotailed with an alpha level
of 5%. All variables were checked for violations against parametric
tests; kurtosis and skewness of each variable was checked to not
extend beyond +/1 (see Supporting Information Figure S1S7 for
plots of the distribution), Cook's distances and individual zscores were
calculated to identify influential cases and outliers, and distributions of
standardized residuals were inspected through QQ plots. Due to non
normal distribution of predictors, we report bootstrapped confidence
intervals and standard errors for correlation and regression analyses
(1000 samples; bias corrected and accelerated (BCa) for the main an-
alyses, percentile for the moderation analyses).
Chronological age differed significantly between samples and
groups, and the SECDI is not standardized for age. Therefore, in all
subsequent analyses we regressed out age from the Core Language
Composite and Total Gesture Scores, by using the residuals of
regression models where age was used as a covariate and the Core
Language Composite and Total Gesture Score respectively was used
as dependent variables.
Developmental antecedents
In accordance with the preregistered analysis plan, this analysis was
made using the combined typical likelihood group. Pearson's corre-
lations were calculated between the Pragmatics Scale, Core Lan-
guage Composite, Total Gesture score and the potential control
variables; chronological age at the 24months timepoint, SES, sex,
and whether Swedish was the first language of either parent (the two
latter dichotomous variables were analysed using pointbiserial cor-
relations (pb). The correlations that included the Pragmatics Scale
was partial, with chronological age at the 24months timepoint as
control variable. To investigate the relative contribution of core
language and social communication on decontextualized language
use we proceeded with a hierarchical regression analysis with the
Pragmatics Scale as dependent variable. Variables were entered in
three prespecified, increasingly complex models: (1) Control vari-
ables, (2) The Core Language Composite and Total Gesture Score, (3)
The interaction term.
Link to symptoms and likelihood of ASD
For the elevated likelihood group, we calculated Pearson's correla-
tions between the Pragmatics Scale and ADOS2 scores. The SECDI
measures were compared between the children with and without
elevated likelihood of ASD using oneway ANOVAs with likelihood
group as factor and chronological age (in days) as control variable. To
test associations with likelihood of ASD, likelihood group was
entered as a main term and a threeway interaction term with the
Core Language Composite and Total Gesture Score in the final model
of the main hierarchical regression analysis, with all lowerlevel
interaction terms.
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ET AL.
Secondary analyses
Specificity analysis
To explore whether the results of the main hierarchical regression
analysis was specific to the Pragmatics Scale, we performed the same
hierarchical regression analysis as in the main analysis, instead using
the Grammar Scale as the dependent variable. This analysis was
carried out using the combined typical likelihood sample, to keep it in
line with the primary antecedent analysis above.
Twin analysis
For the followup twin modelling, we used R software (version 4.0.0)
with the OpenMx package version 2.18.1 with NPSOL optimizer
(Neale et al., 2016) and fullinformation maximum likelihood esti-
mation. Age was regressed from the Pragmatics and Grammar Scales
before being entered in the generalized estimating equation (EEG)
models by using the residuals of regression models with age as co-
variate and the Pragmatics and Grammar Scales respectively as
dependent variables. Sex was added as a covariate in the models.
Twin models estimate the relative contribution of genetic and
environmental factors to the variation in a phenotype and/or to the
covariation between phenotypes, by comparing, respectively, the
correlation between twins or the crosstrait crosstwin (CTCTs)
correlations (the correlation between one phenotype for one twin
and another phenotype for their cotwin). By doing this separately
for monozygotic twins (MZ; who share 100% of their segregating
genetic material) and dizygotic twins (DZ; who on average share
50%), the variation or covariation can be decomposed into additive
genetic influences (A; heritability which increases twin similarity),
nonshared environment (E; environmental influences that differ
between twins and decrease twin similarity, including measurement
error), and shared environment (C; environmental influences that
increase twin similarity regardless of zygosity).
First, univariate modelling of the Pragmatics Scale and the
Grammar Scale were run by fitting saturated models (testing for the
assumptions of equality of mean and variances across twin order and
zygosity) and twin models (testing A, C, and E influences). Then,
bivariate modelling was run by fitting a saturated model and twin
models. For the latter, a correlated factor solution was fitted to
examine the genetic/environment correlations between the Prag-
matics Scale and the Grammar Scale. The best fitting model was
evaluated based on the AIC fit statistic (Akaike information criterion;
the lowest value corresponds to the best model). Twin and CTCTs
correlations were derived from the constrained saturated bivariate
model in which means, variances, and phenotypic and CTCTs corre-
lations were constrained to be equal across twin order and zygosity.
RESULTS
Developmental antecedents
Descriptive statistics are reported in Table 1. In accordance with the
preregistration this analysis was performed on the combined typical
likelihood group. The Pragmatic Scale correlated with the Core
Language Composite (r(203) =0.41, p<0.001, 95%CI [0.28–0.51])
and Total Gesture Score (r(203) =0.33, p<0.001, 95%CI [0.21–
0.43]), as well as sex of the participant (r
pb
(203) =0.42, p<0.001,
95%CI [0.30–0.51]) and chronological age at the 24months time
point (zeroorder; N=206, r=0.19, p=0.008, 95%CI [0.034–
0.310]). It did not significantly correlate with SES (r(203) =0.09,
p=0.213, 95%CI [0.07–0.24]) or whether at least one parent spoke
Swedish as their first language (r
pb
(195) =0.05, p=0.494, 95%CI
[0.11–0.23]), and thus these last two covariates were not included
in the following regression analyses.
All three models in the hierarchical regression analysis (Table 2)
significantly predicted the Pragmatic Scale and yielded significant R
2
change (model 1 (control variables): R
2
=0.20, F(2,203) =25.52,
p<0.001; model 2 (main effects): ΔR
2
=0.10, F(2,201) =14.46,
p<0.001; model 3 (interaction term): ΔR
2
=0.02, F(1,200) =4.80,
p=0.030). The last model, which included the interaction effect,
explained 32% of the total variance. The interaction between the
Core Language Composite and the Total Gesture Score was signifi-
cantly predicting the Pragmatic Scale. Whereas the Core Language
Composite was a significant predictor, the Total Gesture Score was
not.
We followed up the significant interaction effect with a simple
slopes moderation analysis, calculating the relation between the
Total Gesture Score and the Pragmatics Scale at three values of the
Core Language Composite; at mean value, and at one standard de-
viation above and below the mean. This analysis revealed that the
Total Gesture Score predicted the Pragmatics Scale only at low levels
of the Core Language Composite (1 SD: b=0.44, SEM =0.22,
t=1.99, p=0.047, 95%CI [0.01–0.88]; Mean: b=0.16, SEM =0.17,
t=0.92, p=0.359, 95%CI [0.18–0.50]; +1 SD: b= 0.12,
SEM =0.21, t= 0.57, p=0.569, 95%CI [0.54–0.30]). In contrast,
for the relation between the Core Language Composite and the
Pragmatics Scale on the corresponding three levels of the Total
Gesture Score, the Core Language Composite significantly predicted
the Pragmatics Scale at all levels of the Total Gesture Score. As a
sensitivity analysis we performed the main correlation and regression
analyses on only the BATSS sample, excluding the lowlikelihood
group from EASE. The results showed that the overall pattern of
significance was the same as in the analysis of the combined sample
(Appendix S1).
Link to symptoms and likelihood of ASD
Partial correlations, controlling for chronological age, within the
elevated likelihood group showed that, at the 24monthsvisit, the
Pragmatics Scale correlated negatively with the calibrated severity
scores of ADOS2 Total Score (r(91) = 0.36, p<0.001, 95%CI
[.510.19]), and of the two subdomains; Social Affect (r
(91) = 0.35, p=0.001, 95%CI [0.520.16]) and Restrictive and
Repetitive Behaviours (r(91) = 0.26, p=0.013, 95%CI [0.46
0.03]). Neither the Total Gesture Score nor the Core Language
Composite correlated significantly with the ADOS2. To explore the
specificity of the association between decontextualized language
and autistic symptoms, we performed a regression analysis with the
ADOS2 Total Score as dependent variable and the Pragmatics
Scale, the Grammar Scale, and the NonVerbal Developmental Level
(NVIQ) from Mullen Scales of Early Learning (Mullen, 1995) as
predictors. This analysis showed that the association between the
PREPRAGMATIC LANGUAGE USE IN TODDLERHOOD
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Pragmatics Scale and the ADOS2 Total Score remained significant
even after controlling for concurrent Grammar Scale scores and
NVIQ (see Appendix S3 and Table S1S2 for full description,
descriptive statistics and results).
The children in the elevated likelihood group scored significantly
lower on the Pragmatics Scale at 24 months compared to the com-
bined typical likelihood group, after controlling for chronological age,
with a mean difference of 1.06 points (F(1,300) =11.64, p=0.001).
This group difference remained after controlling for concurrent
grammatical ability (F(1,299) =22.62, p<0.001). In contrast, the
groups did not differ on neither the Core Language Composite (F
(1,300) =2.07, p=0.152), the Total Gesture Score (F(1,300) =0.02,
p=0.877), or the Grammar Scale (F(1,300)<0.01, p=0.984).
To investigate if likelihood of ASD moderated the association
between the Total Gesture Score, the Core Language Composite, and
the Pragmatics Scale, we entered the threeway interaction term
(Core Language Composite * Total Gesture Score * likelihood group)
into a regression model with all lowerlevel terms, sex, and
chronological age at the 24months timepoint. This analysis showed
that the threeway interaction was not significant, indicating that the
pattern of prediction did not differ significantly based on likelihood
group membership (Table S3). As an exploratory, not prespecified
analysis we performed the pragmatic scales antecedent analysis on
the elevated likelihood group separately. In this analysis there was a
main effect of the Core Language Composite, but not the Total
Gesture Score, as in the main analysis, but no significant interaction
between these to predictors (Appendix S4 and Table S4).
Secondary analyses
Specificity analysis
When the hierarchical regression analysis was repeated with the
Grammar Scale as the dependent variable, only the Core Language
Composite was a significant predictor, and there was no interaction
TABLE 1Descriptive statistics
Combined typical likelihood group Elevated likelihood group
N=206 N=97
M SD Range M SD Range
Age at 14 Months (days) 438 19 368–501 429 20 389–531
Age at 24 Months (days) 756 26 707–919 743 29 660–838
SES 3.3 0.7 1.5–4.0 3.2 0.9 1.0–4.0
Core language composite (14 Months) 0.15 1.85 3.06 to 5.36 0.32 1.93 3.47 to 4.99
Total gesture score (14 Months) 26.13 8.96 3–52 25.51 8.62 0–46
Pragmatics scale (24 Months) 6.36 2.37 0–10 5.07 2.77 0–10
Grammar scale (24 Months) 3.66 3.04 0–12 3.34 3.27 0–12
TABLE 2Predictors of the pragmatics scale: typical likelihood group
bStd. Error 95% CI t p
Model 1
Sex
a
1.93 0.30 1.35, 2.53 6.51 0.001
Age
b
0.02 0.01 0.01, 0.02 2.57 0.002
Model 2
Sex
a
1.51 0.29 0.94, 2.07 5.16 0.001
Age
b
0.01 0.01 0.01, 0.02 2.48 0.003
Core language composite 0.69 0.16 0.39, 1.01 4.03 0.001
Total gesture score 0.14 0.16 0.18, 0.49 0.81 0.386
Model 3
Sex
a
1.46 0.29 0.89, 2.03 5.00 0.001
Age
b
0.01 0.01 0.01, 0.02 2.35 0.006
Core language composite 0.71 0.16 0.41, 1.03 4.19 0.001
Total gesture score 0.16 0.16 0.16, 0.46 0.92 0.329
Core language composite * total gesture score 0.28 0.12 0.53, 0.05 2.19 0.023
a
Reference level: Male.
b
Chronological age at the 24month timepoint (days).
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between the Core Language and Total Gesture Scores (see Appen-
dix S2 for full results). The Pragmatic Scale correlated significantly
with the concurrent Grammar Scale (r(203) =0.62, p<0.001, 95%CI
[0.54–0.70]).
Twin analysis
Descriptive statistics for the twin sample are reported in Table S5.
There was a significant effect of sex on both the Grammar Scale
(p=0.002) and the Pragmatics Scale (p<0.001).
The twin correlations for monozygotic pairs were higher than for
dizygotic pairs for the two scales (Pragmatics Scale: MZr =0.75, 95%
CI [0.65–0.82] and DZr =0.41, 95%CI [0.22–0.56]; Grammar Scale
MZr =0.74, 95%CI [0.65–0.81] and DZr =0.55, 95%CI [0.37–0.67]),
suggesting genetic influences on both. Univariate twin modelling
confirmed the genetic contribution to the Grammar and Pragmatics
scales, and suggested that shared environment only had an influence
on the Grammar Scale (Tables S6S9). For this reason, a bivariate
model with A, C, and E influences explaining the variation in
grammar, and A and E influences explaining the variation in prag-
matics, was tested alongside ACE, AE, CE, and E models. The ACEAE
model was the best fitting model with the lowest AIC statistic. This
model did not fit significantly worse than the ACE model, while
dropping the C component of the Grammar Scale (the AE model) had
a marginally significant poorer fit (Tables S7 and S9). The estimates
from the ACEAE model showed that the genetic correlation be-
tween the two measures was 0.90 (95%CI [0.68–0.1]; Figure 1, Ta-
ble S10). The upper bound of the CI of 1 indicates the possibility of a
complete overlap in the genetics explaining these measures. See
Table S11 for test of the assumption of equality of phenotypic and
CTCTs correlations across twin order and zygosity.
DISCUSSION
Our results suggest that compared to early sociocommunicative
abilities, early core language abilities have stronger longitudinal as-
sociations to later decontextualized language use. However, socio
communication and core language interacted in predicting decon-
textualized language, indicating that children with lower levels of
early core language might draw from sociocommunicative abilities to
compensate for general language deficits in the development of this
potential early pragmatic function. This is in line with the hypothesis
put forward by Wilson and Bishop (2019,2021a), proposing that
early in development, pragmatics, core language, and socio
communication may be more closely intercorrelated than for more
proficient language users.
As hypothesized, the use of decontextualized language was
negatively associated with concurrent autistic symptoms in two
yearolds belonging to a group with elevated likelihood of ASD due
to having a firstdegree relative with the condition. Neither general
nonverbal developmental level nor concurrent core language abili-
ties could explain this association, which is line with what Wilson and
Bishop (2021b) found in adults with ASD. Further, the children with
elevated likelihood of ASD used decontextualized language signifi-
cantly less than the typicallikelihood children. In contrast, the groups
scored similarly on core language and social communication at
14 months as well as grammatical ability at 24 months of age. This
was unexpected, given that children with elevated likelihood of ASD
has been reported previously to exhibit difficulties with both core
language and social communication at this age (Lazenby et al., 2016;
Zwaigenbaum et al., 2005). Taken together, these findings suggest
that already in toddlerhood, decontextualized language use is inde-
pendently associated with dimensional aspects of autism as well as
with having familial elevated likelihood of developing ASD.
We made two additional explorative analyses to investigate if
the developmental antecedents of decontextualized language use
extended also to concurrent grammatical language use, and if these
two aspects of language use share genetic and environmental aeti-
ology. We found that in contrast to decontextualized language, there
was no interaction between core language and social communication
in predicting grammatical language ability at 2 years, suggesting a
difference in the patterns of antecedents between pragmatic versus
core language ability. Pragmatic language (measured here by decon-
textualized language) and core language (measured by grammatical
language) were moderately correlated at 2 years age in our sample
(r=0.62), and the twin analyses indicated that most, if not all, of the
genetic influence on one aspect were shared with the other. This
result suggests that pragmatic and core language are quite strongly
associated at this age. On the other hand, the twin analyses also
indicated a difference between decontextualized and grammatical
language use, in regard to the relative contribution of genetics and
shared environment to their respective variances. While shared
environment seemed to have an influence on grammar use, this was
not the case for the variance in decontextualized language which
could be explained solely by genetics and unique environment. Taken
together, these results could suggest that even in early development,
core language, as measured by grammatical language use, and prag-
matics, as measured by decontextualized language use, are associ-
ated yet differentiated language domains both on the level of
aetiology, developmental antecedents, and behaviour. This is in line
with the Relevance Theory, which places pragmatics as a socio
cognitive capacity in its' own right, separable from core language
while still related to it (Carston, 2002; D. Wilson & Sperber, 2002).
Better grammatical ability should facilitate the use of decon-
textualized language. Conversely, the ability to talk about pragmati-
cally and conceptually advanced phenomena should promote the use
of more complex grammar. The Grammar Scale also includes items of
both the possessive form and past tense; grammatical structures that
are associated with decontextualized language as they are related to
talking about things and events beyond the here and now. Our
findings that the Pragmatics and Grammar Scales are correlated and
that early core language ability might be important for decontex-
tualized language use are therefore not surprising. The fact that we
still find differences between these scales in terms of longitudinal
prediction and influence of environmental factors suggests that these
two scales capture different aspects of early language ability.
The finding that grammatical and decontextualized language use
shared almost all of their genetic influence is noteworthy given the
clinical association between ASD and pragmatic ability but not
necessarily grammatical ability, and the fact that ASD is a highly
heritable condition. However, we cannot rule out the possibility of
unique genetic influences on either ability, albeit small and
PREPRAGMATIC LANGUAGE USE IN TODDLERHOOD
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nonsignificant in our study. Therefore, it is yet possible that there
are unique genetic influences on decontextualized language that in
turn overlaps with genes associated with ASD. Another possibility,
not mutually exclusive, is that the added contribution of shared
environment to the variance in grammar use (but not to decontex-
tualized language) plays a role in the distinction seen between these
two linguistic constructs and ASD. It is also important to note that
while we tested the relative genetic and environmental influences on
grammar and pragmatics at 2 years of age, the pattern might change
at older ages (HayiouThomas et al., 2012).
In our study the relationships between core language and social
communication was not moderated by likelihood of ASD, indicating
that the relative contribution of core language and social communi-
cation to decontextualized language use is similar in autistic and
typical development. However, when performing the developmental
antecedent analysis on the elevated likelihood group separately, we
did not find a significant interaction between core language and so-
cial communication in predicting decontextualized language use in
this group. This is in contrast to what we found for children with
typical likelihood of receiving an ASD diagnosis, and could suggest
that children with elevated likelihood of ASD may depend less on
social communication abilities in the development of decontextual-
ized language. However, because this analysis was explorative, we
hesitate to draw strong conclusions regarding this finding.
Pragmatic ability in childhood has been shown to be associated
with important social facets of life, not only for children with ASD
(Whitehouse et al., 2009). As such, early intervention directed to-
wards improving pragmatic ability might be important not only for
children at elevated likelihood of ASD (Klin et al., 2007), but also for
the general population. Indeed, variation in early decontextualized
language use spanned both our typical likelihood and elevated like-
lihood groups. Intervention trials are needed in order to understand
causal effects, but in order to develop welltargeted interventions, it
is important to first have a detailed understanding of the antecedents
of pragmatic abilities. Other individual factors, such as theory of
mind, working memory (Zufferey, 2016) or domaingeneral
inferential processing (A. C. Wilson & Bishop, 2019) may also be
important for early pragmatic development, but if decontextualized
language is found to be a valid marker of early pragmatic ability, our
results indicate also core language as a potentially important target
for intervention. Further, based on the interaction between core
language and social communication in predicting decontextualized
language use, support of social communication could prove beneficial
to pragmatic development for young children with delayed or
impaired core language abilities.
A potential critique against the decontextualized language
measure and our interpretation thereof is that even though decon-
textualized language may be regarded as a pragmatic aspect later in
language development, this is not necessarily the case in early lan-
guage development when the conversational partner need make
contextual interpretation to understand the statement. Three of our
findings corroborate the view that decontextualized language use
could be regarded as a pragmatic subskill or precursor already this
early in development. First, the finding that decontextualized lan-
guage was associated with dimensional autistic traits, independently
from general development and core language. Second, the finding
that core language and social communication were differently linked
to decontextualized and grammatic language use. Third, the finding
that environmental factors differentially influenced decontextualized
and grammatic language use. Taken together, these findings suggest
that what we measure with decontextualized language captures
something beyond core language that is also independently associ-
ated with autism, which is what we would expect from a measure of
early pragmatic ability. We find this dissociation between decon-
textualized and core language despite the conceptual similarities
between the pragmatics and grammar scales, and despite the fact
that both measures are rated by the same parents at the same time,
both of which would increase the expected intercorrelation between
measures. However, it is a limitation to our study that we only
measured one specific early prepragmatic skill, decontextualized
language, because there is a lack of previous research validating this
measure as specifically pragmatic. To know if our conclusions
FIGURE 1 Scheme of the bivariate twin model for the Grammar and Pragmatics Scales at 24 months age. A =genetic influences,
C=shared environment influences, E =unique environment influences.
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generalize to other pragmatic abilities we (1) need studies that
associate decontextualized language to other pragmatic skills and (2)
need to replicate our analysis on other pragmatic skills. This second
point, regarding replication, also applies to grammatical ability and
sociocommunication, although we measured both semantic and
syntactic understanding (in the case of the first) and a rather broad
array of social communication abilities (in the case of the second).
Further, most of our measures were based on parental report. While
this is a limitation for example, due to common method bias and due
to difficulty for parents to rate their own children, parental reports
also have advantages as they sometimes can give a better picture of
certain abilities, such as pragmatics, than what can be captured in
formal evaluation (M. Miller et al., 2015). Lastly, there are consid-
erations related to twin births that may challenge the assumption
that twins are representative of the general population. In this re-
gard, we excluded participants with developmental concerns, and we
discerned no significant differences in our measures between the
BATSS sample and the lowlikelihood group from EASE. We there-
fore conclude that this combined typicallikelihood group are
generally typically developing in the ways relevant for our conclu-
sions, but replication in a nontwin sample would be advisable in
future studies.
CONCLUSION
We found that for young children with and without elevated likeli-
hood of ASD, core language is a strong predictor of decontextualized
language use, and that sociocommunicative abilities may be an
important resource for children with lower levels of early general
language ability in their development of this potential early pre
pragmatic language ability. We also found associations between
decontextualized language use and autistic symptoms beyond what
could be explained by general language ability or developmental
level. Further, our results suggests that decontextualized language
and core language are phenotypically and genetically associated yet
independent aspects of language already early in development. As
such, our results add to the understanding of longitudinal and
aetiological factors underlying early pragmatic development both in
typical and in nonneurotypical development.
AUTHOR CONTRIBUTIONS
Maja Rudling: Conceptualization; Data curation; Formal analysis;
Methodology; Visualization; Writing original draft. Ana Maria
Portugal: Data curation; Formal analysis; Methodology; Visualization;
Writing review & editing. Sven Bölte: Investigation; Project
administration; Resources; Writing review & editing. Terje Falck
Ytter: Conceptualization; Funding acquisition; Methodology; Project
administration; Resources; Supervision; Writing review & editing.
ACKNOWLEDGEMENTS
The authors would like to thank the participating children and fam-
ilies and the colleagues in EASE and BATSS. This study was funded by
the Swedish Research Council (grant 2018–06232), Riksbankens
Jubileumsfond in collaboration with the Swedish Collegium for
Advanced Study (Pro Futura, grant NHS141802:1), the Knut and
Alice Wallenberg Foundation, and the Innovative Medicines Initiative
2 Joint Undertaking (grant 777394; this Joint Undertaking receives
support from the European Union's Horizon 2020 research and
innovation programme and EFPIA and AUTISM SPEAKS, Autistica,
SFARI). The work leading to these results was also supported by
funds from the European commission (H2020 project CANDY; grant
847818). The funders had no role in the design of the study; in the
collection, analyses, or interpretation of data; in the writing of the
manuscript, or in the decision to publish the results.
CONFLICTS OF INTEREST
The authors have declared no competing or potential conflicts of
interest in relation to this article. S.B. discloses that he has in the last
5 years acted as an author, consultant, or lecturer for Medice and
Roche. He receives royalties for textbooks and diagnostic tools from
Hogrefe (e.g., ADOS2, ADIR, SRS2). He is shareholder in SB Edu-
cation/Psychological Consulting AB and NeuroSupportSolutions In-
ternational AB.
OPEN RESEARCH BADGES
This article has earned a Preregistered Research Designs badge for
having a preregistered research design, available at https://doi.org/
10.17605/OSF.IO/D6VJS.
DATA AVAILABILITY STATEMENT
The data that supports the findings of this study are available from
the corresponding author upon reasonable request. Transfer of data
will require a data processor agreement according to EU legislation
(GDPR). The data are not publicly available because they contain
information that could compromise research participant privacy/
consent.
ETHICAL CONSIDERATIONS
BATSS and EASE were approved by the Regional Ethical Board in
Stockholm, Sweden and conducted in accordance with the 1964
Declaration of Helsinki. Informed consent was collected from all
parents.
ORCID
Maja Rudling https://orcid.org/0000-0003-3811-5471
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How to cite this article: Rudling, M., Portugal, A. M., Bölte, S.,
& FalckYtter, T. (2023). Prepragmatic language use in
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