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Citation: Dohmen, A., Bishop, D.V., Chiat, S. & Roy, P. (2016). Body movement imitation and early language as predictors of later social communication and language outcomes: A longitudinal study. Autism & Developmental Language Impairments, 1, doi: 10.1177/2396941516656636

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Research Article

Body movement imitation and early languageas predictors of later social communicationand language outcomes: A longitudinal study

Andrea DohmenHochschule fur Gesundheit, Germany; University of Oxford, UK

Dorothy VM BishopUniversity of Oxford, UK

Shula Chiat and Penny RoyCity University London, UK

Abstract

Background and aims: Over recent decades much research has focused on detecting predictors of different language

trajectories in children with early language delay but there has been very little exploration of social communication

trajectories in these children. We report a longitudinal study that investigated the predictive value and clinical significance

of elicited body movement imitation and language for later social communication and language outcome in Late Talkers.

Methods: Participants were 29 German-speaking children who were identified with delayed onset and progression of

language at two years and followed up at four years. Novel assessments of posture and gesture imitation were admin-

istered at Time 1, together with standardised language measures. All body movement imitation items involved self-other

mappings, assumed to rely on sociocognitive capacities. At Time 2, children were assessed on standard language tests,

together with parental reports of social communication.

Results: Early language skills at Time 1 were significantly associated with later language outcome and body movement

imitation skills at Time 1 with later social communication outcome. Logistic regression analyses revealed that body

movement imitation as well as language at Time 1 added significantly to the prediction of language outcome at Time 2,

whereas only body movement imitation made a significant contribution to the prediction of social communication

outcome at Time 2.

Conclusions and implications: Theoretically, results highlight the need to account for the heterogeneity of different

language and communication trajectories in children with early language delay and point to the importance of socio-

cognitive difficulties observed in some of these children. Clinically, this study demonstrated that body movement imi-

tation measures have the potential to improve the identification of pre-schoolers who are at risk of later social

communication and language problems.

Keywords

Body movement imitation, sociocognition, late talkers, language, social communication

Introduction

Some otherwise typically developing toddlers havedelayed onset and progression of language for noapparent reason. These children are widely referred toas Late Talkers (LT) in the literature (Rescorla & Dale,

2013). A substantial number of LTs move into the typ-ical range on standardised language measures duringthe preschool period, but a subset continues with lan-guage impairments throughout the school years(Domsch et al., 2012; Ellis & Thal, 2008; Henrichset al., 2011; Moyle, Weismer, Evans, & Lindstrom,

Corresponding author:

Andrea Dohmen, Division Speech & Language Therapy, Department of Applied Health Sciences, Hochschule fur Gesundheit, Gesundheitscampus 6-8,

44801 Bochum, Germany.

Email: andrea.dohmen@psy.ox.ac.uk; andrea.dohmen@hs-gesundheit.de

Autism & Developmental Language

Impairments

Volume 1: 1–15

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2007; Paul & Roth, 2011; Rescorla, 2011; Westerlund,Berglund, & Eriksson, 2006). LTs do not constitute ahomogeneous group but present with varied profiles oflanguage and/or social communication skills and def-icits which change over time: some present with expres-sive language problems only, whereas others alsoevidence limited receptive language and/or social com-munication skills that border on Autism SpectrumDisorders (ASD) (Desmarais, Sylvestre, Meyer,Bairati, & Rouleau, 2008; Ellis & Thal, 2008; Hawa& Spanoudis, 2014; Paul & Ellis Weismer, 2013; Paul& Roth, 2011). But although some LTs and young chil-dren with ASD share common features, it is importantto acknowledge that not all late-talking toddlers withsocial communication deficits meet diagnostic criteriafor ASD. In this study, we focussed on toddlers whopresented with delayed language and communicationskills for no apparent reason and no child in thisstudy had a clinical diagnosis of ASD.

The term LTs has been used in various ways.Traditionally, LTs have been identified by expressivelanguage delay, using different language measures andcut-off criteria at different points in age. Some studieshave excluded children with receptive delays, but thisrestricts generalisability of findings. The term LT asused in this study includes children with both expressiveonly and expressive–receptive delays as the exclusivefocus on expressive delay runs the risk of coveringonly a certain proportion of children with late languageemergence.

Clinically, it is important to identify LTs who are athigh risk of significant language impairments when theyget older, so that early intervention services can be dir-ected to this subset. Consequently, much research hasfocused on detecting predictors of different languagetrajectories in young children with late language emer-gence. This has shown that prediction of language out-come is poor if reliance is only placed on expressivelanguage measures, especially when using earlyparent-report measures of language development(Dale, Price, Bishop, & Plomin, 2003; Feldman et al.,2005; Henrichs et al., 2011; Westerlund et al., 2006).There is a need for multifactorial predictive riskmodels that include a wide range of verbal and nonver-bal factors (Desmarais et al., 2008; Ellis & Thal, 2008;Hawa & Spanoudis, 2014; Olswang, Rodriguez, &Timler, 1998; Paul & Roth, 2011; Zambrana, Pons,Eadie, & Ystrom, 2014). To date, numerous perinatal(e.g. foetal growth (Rice, 2012; Zubrick, Taylor, Rice,& Slegers, 2007)), parental and demographic (e.g.maternal education (Dale et al., 2003), socioeconomicstatus (Horwitz et al., 2003) and child factors (e.g. lim-ited symbolic play (Rescorla & Goossens, 1992)) havebeen studied. At a group level, all these factors seem topredict poor language outcome to some extent, but

results are inconsistent and predictive value of outcomein individual cases is still too inaccurate to provide clin-icians with a reliable guide in deciding which LTsshould receive early language intervention (Daleet al., 2003; Henrichs et al., 2011; Rice, Taylor, &Zubrick, 2008; Westerlund et al., 2006). The more reli-able risk factors appear to be a delay in language com-prehension (Bishop et al., 2012; Ellis Weismer, 2007;Henrichs et al., 2011; Silva, 1980; Thal, Tobias, &Morrison, 1991; Zambrana et al., 2014), a family his-tory of language and literacy difficulties (Bishop, Price,Dale, & Plomin, 2003; Lyytinen, Eklund, & Lyytinen,2005; Reilly et al., 2010; Rice, 2012; Zambrana et al.,2014; Zubrick et al., 2007) and male gender (Henrichset al., 2011; Horwitz et al., 2003; Reilly et al., 2010;Zambrana et al., 2014; Zubrick et al., 2007). It alsoseems to be generally accepted that the more risk fac-tors are present, the higher the risk for persistent lan-guage deficits and the greater the need for clinicalintervention (Desmarais et al., 2008; Ellis & Thal,2008; Hawa & Spanoudis, 2014; Henrichs et al., 2011;Olswang et al., 1998; Paul & Roth, 2011). However,prediction at the individual level remains poor.

Nonverbal and social communicationtrajectories in Late Talkers

Some studies of children with delayed languageemergence have looked beyond spoken language toconsider nonverbal aspects and found that LTs receivedpoorer scores than controls on measures of symbolicplay (Rescorla & Goossens, 1992), imitation of pretendacts (Dohmen, Chiat, & Roy, 2013; Thal & Bates,1988), imitation of postures and gestures (Dohmenet al., 2013), spontaneous use of gestures (Thal, Bates,Goodman, & Jahn-Samilo, 1997) and communicativeacts (Bonifacio et al., 2007; Desmarais et al., 2008;MacRoy-Higgins & Kaufman, 2012; van Balkom,Verhoeven, & van Weerdenburg, 2010).

However, there has been very little exploration ofthese nonverbal trajectories across age; most studiesin this area have been cross-sectional, or if looking atoutcomes, have focused on spoken language trajec-tories. To our knowledge, only four studies have inves-tigated relations between these types of nonverbal skillsin LTs and their later language and/or social commu-nication outcome using a longitudinal design.

Thal et al. (1991) followed-up language trajectoriesin a small group of 18-32-month-old LTs one year afterthey assessed them on two tasks which required theimitation of different types of pretend acts: the imita-tion of single pretend acts with appropriate and substi-tute objects and the imitation of sequences of pretendacts with appropriate objects (all designated as use ofsymbolic gestures). They found that the group of

2 Autism & Developmental Language Impairments

children who were categorised as true LTs (n¼ 4) atTime 2 (T2), i.e. those children who still demonstratedexpressive language delay at follow-up, performed sig-nificantly worse than the group of late bloomers (n¼6),i.e. those children who caught up with their typicallydeveloping peers, on both pretend imitation tasks atTime 1 (T1).

Zambrana et al. (2014) studied whether an integra-tive model of risk factors including limited early com-munication skills, family history of languagedifficulties, delayed language comprehension and malegender would predict later persistent, recovering andlate-onset trajectories of language delay in a large popu-lation-based cohort study (n¼ 10,587). Children’s com-munication skills at 18 months were measured usingfour items from the Modified Checklist for Autism inToddlers (Robins, Fein, Barton, & Green, 2001) andthe Ages and Stages Questionnaire (Richter & Janson,2007), asking parents about children’s abilities to usepointing to initiate different communicative acts and tospontaneously imitate different types of everydayactions. Language outcome at 3–5 years was assessedusing a subset of questions of the Ages and StagesQuestionnaire, a parental questionnaire that focuseson children’s oral language skills but also taps theirabilities to use language in social contexts. Thus, thequestionnaire seems to measure language forms andstructures as well as language use but does not differ-entiate between different outcome profiles of languageand social communication. Results showed that poorcommunication skills at 18 months were associatedwith all trajectories of language delay from 3–5 years,but the effects were small.

Pesco and O’Neill (2012) investigated the ability ofthe Language Use Inventory (O’Neill, 2007) to predictlanguage outcomes of 348 children at 5–6 years whohad been assessed with the Language Use Inventoryat 18–47 months. Findings revealed a very respectablepredictive validity of the Language Use Inventory forlater language outcome for children aged 24–47 monthsbut was less convincing for children aged 18–23months. The Language Use Inventory is a 180 itemsparent report designed to measure children’s languageuse in everyday situations while focusing on oral lan-guage. Children’s language outcome was assessed usingthree standardised tests: the Diagnostic Evaluation ofLanguage Variation – Norm Referenced (Seymour,Roeper, & de Villiers, 2005), designed to measure chil-dren’s syntactic, semantic and pragmatic skills; theClinical Evaluation of Language Fundamental –Preschool, 2nd Edition (Wiig, Secord, & Semel, 2004),designed to measure different language skills at wordand sentence level, and the Children’s CommunicationChecklist – 2nd Edition, U.S. Edition (Bishop, 2006),designed to measure children’s pragmatic skills in

everyday situations. Children’s performance at T2 wascategorised as presenting with language difficultieswhen they scored below the seventh percentile on oneoutcome measure or had been diagnosed with languagedifficulties since T1 according to parental report.Positive cases might therefore have presented withvaried profiles of language and/or social communica-tion problems which were not further specified by theauthors.

Chiat and Roy (2008, 2013) evaluated the hypothesisthat early sociocognition would predict later languageand social communication outcome in young childrenreferred to speech and language therapy services due toconcern about language development. At the age of2;6–4;0 (T1), three different sociocognitive skills,social responsiveness, joint attention and symbolicunderstanding, were measured using the EarlySociocognitive Battery (Chiat & Roy, 2006). All taskswere essentially nonverbal. Children’s language andsocial communication skills were followed up at theages of 4–5 years (T2, n¼ 163) and 9–11 years (Time3; T3, n¼ 108), using direct language assessment anddifferent parental questionnaires tapping social com-munication. Difficulties with the Early SociocognitiveBattery were significantly associated with later socialcommunication problems at T2 and T3 at group andcase level, suggesting that deficits in sociocognition at2;6–4;0 years contribute to children’s later social com-munication problems. At 9–11 years, four distinct sub-groups with language impairment only (LI), socialcommunication impairment only (SCI), both languageand social communication impairments (LI-SCI) orneither problem, were identified. Investigation of devel-opmental trajectories revealed that the three impairedgroups (LI, SCI and LI-SCI) did not differ on languageor parent ratings of social, emotional and behaviouraldifficulties when first seen. Only performance on theEarly Sociocognitive Battery differentiated the childrenwith and without social communication problems sevenyears later, at 9–11 years (Roy & Chiat, 2014).Nonetheless, the authors conclude that, while theEarly Sociocognitive Battery is valuable, it is not suffi-cient to predict all deficits in social communication.

Overall, all four studies found some type of relationbetween early sociocognitive and/or nonverbal commu-nication skills and later language or social communica-tion outcomes in young children with a delayed onset oflanguage. This suggests that early sociocognitive andnonverbal communication behaviours are promisingpredictors of children’s language and/or social commu-nication trajectories with the potential to inform thedecision-making process of speech and language ther-apists. Interestingly, most studies focus solely on chil-dren’s language outcomes, without looking separatelyat their social communication skills. This neglect is

Dohmen et al. 3

surprising, given that the heterogeneity of the popula-tion of children with specific deficits in language is wellestablished (Leonard, 1998). It is also remarkable con-sidering that most intervention programmes for chil-dren with late language emergence are designed tofacilitate children’s and parents’ communication skillsas a catalyst for everyday language and social commu-nication (e.g. Hanen Training Program (Manolson,1992)). The overview also highlights the struggle tofind strong predictors for children aged 18–24 months,suggesting that 18 months might simply be too young totry and identify long-term problems. Recent findingsprovide some indication that the prediction of laterproblems improves with age (Dale & Hayiou-Thomas,2013; Dollaghan & Campbell, 2009; Duff, Plunkett,Nation, & Bishop, 2015), but our understanding ofhow heterogeneous language and communication trajec-tories might change over specific age bands in toddlerswith language delay remains limited.

The mapping theory

This study aimed to add to the understanding of theheterogeneity of early language and social communica-tion trajectories. It investigated body movement imita-tion and general language skills of LTs as predictors oftheir later social communication and language out-comes and is rooted in the mapping theory (Chiat,2001; Chiat & Roy, 2008). The mapping theoryargues that language impairments must arise from abreakdown at some point in the mapping process, i.e.the discovery of forms, the discovery of meanings andthe acquisition of connections between form and mean-ing which are specific to a language (Chiat, 2001). Thetheory focuses on two sets of early processing skills,sociocognitive and phonological, which are hypoth-esised to be crucial to this process. These skills havebeen associated with concurrent and later languageand social communication abilities, and it is proposedthat either or both may be the source of deficits in lan-guage. The sociocognitive hypothesis focuses on chil-dren’s abilities to use a range of pragmatic cues in orderto infer the meaning intentions behind speakers’ utter-ances and hence discover the meaning of their words.These sociocognitive skills are therefore argued to havea ‘bootstrapping’ role in language. They are also crucialfor social communication. It is therefore predicted thatdifficulties with sociocognition will affect the develop-mental trajectory through which language and socialcommunication emerge. Since nonverbal imitationskills are assumed to rely significantly on sociocognitiveabilities (Carpenter, Pennington, & Rogers, 2002;Tomasello & Carpenter, 2005) but do not involve theprocessing of structural aspects of language, we arguethat difficulties with elicited body movement imitation

provide a window onto sociocognitive abilities inde-pendently of difficulties with the processing of the struc-tural aspects of language. To date, a wealth of studieshave addressed nonverbal imitation deficits in childrenwith ASD, who are known to have sociocognitive diffi-culties, but nonverbal imitation has barely beenexplored in LTs (see Dohmen et al., 2013 for moreinformation).

The current study

Results from the initial phase of this longitudinalstudy, at T1, were reported in Dohmen et al. (2013).We compared typically developing children and LTsaged 2;0–3;5 years on a range of novel nonverbal imi-tation tasks that to a greater or lesser extent involvedsociocognitive skills. It was hypothesised that at agroup level the LT sample would perform significantlybelow the typically developing sample on imitationtasks categorised as ‘social’ (i.e. the imitation ofbody movements), while imitation tasks categorisedas ‘instrumental’ (i.e. the imitation of actions onobjects) would be no more challenging for the LTsample than the typically developing sample. Inorder to investigate whether and how imitation andlanguage profiles might change over age, childrenwere divided into three 6-months age bands withinthe typical and clinical samples (2;0–2;5; 2;6–2;11;3;0–3;5). In line with our hypotheses, significantgroup differences were found for all body movementimitation tasks but not for the actions on objectstasks. However, while the majority of 2-year-old LTsscored substantially below their typically developingpeers on body movement imitation, most 3-year-oldLTs scored within the range of their typically devel-oping peers. Group differences in the 3-year-old weredue to a minority of children who emerged as outliers.

Here we report a follow-up study (T2) investigatingthe predictive value and clinical significance of elicitedimmediate body movement imitation tasks and recep-tive and expressive language tests for social communi-cation and language outcomes two years after T1, whenchildren were aged four years. All body movement imi-tation items involved self-other mappings which wereassumed to rely on sociocognitive capacities. Thesetasks focussed exclusively on the demonstrator as aperson and required the imitator to connect andengage socially with this unfamiliar person in ashared activity. The instrumental tasks involvingobjects or an observable functional outcome that didnot differentiate the groups at T1 were excluded. Weaimed to evaluate the following hypotheses:

1. Performance on general language tests at T1 willpredict language outcome at T2.

4 Autism & Developmental Language Impairments

2. Performance on body movement imitation tasks atT1 will predict social communication and languageoutcome at T2.

Methods

Procedures

Approval for data collection at T1 was given by theCity University School of Community and HealthSciences Research Ethics Committee (referencenumber: PhD/08-09/05) and approval for the follow-up study at T2 by the Central University ResearchEthics Committee of the University of Oxford (refer-ence number: MSD-IDREC-C2-2012-24). Participantswere recruited to this study by paediatricians, speechand language therapists, phoniatricians and nurseryteachers from clinical institutions and nurseries in theareas of Bonn and Magdeburg in Germany (Dohmenet al., 2013). Each participant was seen individually atthe child’s home, nursery or clinic and parents gavesigned consent for their own and their child’s partici-pation prior to the assessments. Assessments atboth phases were administered in a fixed order. AtT1, children were seen for two or three sessions lasting30–45min, and at T2 for one or two sessions lasting45–60min. Questionnaires relating to the child’s gen-eral developmental history were given to parents atboth stages to return in stamped addressed envelopes.

Participants

Twenty nine of the 30 children who were identified withdelayed onset and progression of language at two yearswere followed up at four years (one child could not becontacted and was excluded from all analyses). We alsoexcluded the six children available for follow-up whohad been in a group of 15 children ages 3;0–3;5 at T1, asthe attrition rate was so high. Thus, the current studyreports data for 29 children reassessed two years afterfirst being seen at ages 2;0–2;11. At the time of referral,all children had German as their main language, nosignificant history of general developmental delay ordisorder, and met the criteria for delayed languagedevelopment (see Language: T1 and T2). No childhad a clinical diagnosis of ASD at T1 or T2.

At T1, the inclusion criterion for nonverbal abilitywas a standard score� 85 on a German translation ofthe Special Nonverbal Composite of the British AbilityScales II (BAS II (Elliott, Smith, & McCulloch, 1996))for the two older age groups (Table 1). Since there wasno suitable measure for children under 2;6 years, chil-dren’s nonverbal cognitive development within theyoungest age group was checked through parentalquestionnaires and by questioning health professionals

who had referred participants (Dohmen et al., 2013). AtT2, nonverbal ability was measured using a Germantranslation of Pattern Construction, a subtest of theBAS II, in which the child is asked to construct adesign by putting together squares/cubes with blackand yellow patterns. All children scored in the averagerange, with scores at or above one SD of the mean(�85, Table 1). At T1 the children were also screenedon the gross and fine motor development subtests of theEntwicklungstest 6-6 (Petermann, Stein, & Macha,2005). All children had motor skills above the 10th per-centile and no significant differences were foundbetween the performance of the typically developingand LT groups. Subtests of the BAS II and theEntwicklungstest 6-6 were exclusively used to ensurethe fulfilment of the selection criteria to define partici-pant groups and not intended for further analyses.

Assessments

Body movement imitation. At T1, all children wereassessed on a novel imitation battery that included arange of nonverbal (four body movement tasks andthree action on object tasks; see Dohmen et al., 2013for full details) and verbal (word, nonword and sen-tence repetition) imitation tasks. The imitation batteryalternated between body movement, actions on objectsand verbal tasks and was presented in two counterba-lanced orders to control for fatigue and practice effects.All nonverbal imitation tasks were embedded in game-like contexts that were specifically designed to keepchildren at this young age engaged and to elicit imme-diate responses with a minimum of verbal instructions.

The body movement imitation tasks required theimmediate imitation of 23 body movements: Fivefacial postures and expressions (e.g. open and closemouth), 10 manual postures (e.g. pat elbow), four con-ventional gestures (e.g. wave for greeting) and fourobject-related gestures (e.g. pretend to throw a ball;

Table 1. Age (months) and nonverbal (NV) cognitive abilitya

of participants of the longitudinal study at T1 and T2 (n¼ 29).

Age

group (T1) n

Age

mean (SD)

NV cognitive

ability

mean (SD/range)

T1 2;0–2;5 18 26.0 (1.25) –

2;6–2;11 11 31.8 (1.40) 97.8 (4.51/95–127)

T2 2;0–2;5 18 55.2 (3.09) 107.9 (8.06/93–122)

2;6–2;11 11 62.0 (1.55) 107.8 (11.76/92–125)

aScores shown as standard scores (mean� SD of 100� 15), n¼ number

of participants.

Dohmen et al. 5

see Table 2 for full details). All target items involvedself-other mappings but none involved objects or anobservable functional outcome (see Dohmen et al.,2013 for full details). In each body movement imitationtask, the instructor and child were seated opposite toeach other on the floor. The instructor told the child: ‘Iknow a really funny game. Look!’. After she was surethat she had the child’s full attention, she modelledeach target item twice and then invited the child toact by saying: ‘Now you (do it)!’. If the child did notshow any reaction within 5 s the investigator modelledthe item again, followed by a second invitation. Sinceeach item was demonstrated twice and the procedureallowed for two trials per test item children observeditems up to four times.

Facial postures and expressions (5 items) werescored with a simple pass–fail coding scale for attempt(1) or refusal (0) to imitate, since piloting revealed that

it was not possible to reliably score these in a moregraduated way (maximum total¼ 5). Manual postures(10 items), conventional gestures (4 items) and object-related gestures (4 items) have clearer componentsallowing for reliable differentiation of attempts to imi-tate and were scored using a more graduated codingscale for accurate (2), partial (1) and unrelated (0) imi-tation responses and refusal to imitate (0) (maximumtotal¼ 36). For the follow-up study, a body movementimitation composite score of all 23 items was derived bysumming each child’s raw scores for all T1 posture andgesture tasks yielding a maximum raw score of 41(henceforth referred to as body movement imitationscore; see Table 2 for full scoring criteria).

Categorical classification on T1 body movement

imitation. As reported in ‘Introduction’ section, signifi-cant differences between groups of typically developing

Table 2. Body movement imitation tasks (23 items yielding a maximum score of 41).

Target body movements Scoring

Facial postures and expressions: 5 items (5)a

� Open and close mouth

� Protrude tongue

� Close and open eyes

� Anger

� Happiness

1 (attempt)¼ attempt to move relevant parts of the face

0 (refusal)¼ no facial movement

Manual postures: 10 items (20)a

� Pat top of head with hand

� Grab nose

� Pat tights with hands

� Pull ear with one hand

� Pull ears with both hands

� Touch shoulder

� Pat elbow

� Lift one finger

� Form and open fist

� Form T-sign

2 (accurate)¼ entire body movement reproduced as specified

1 (partial)¼ response showed some but not all features of the target act

in terms of

� chosen body parts and/or plane and direction of movement

� a visible attempt to represent a specified communicative function or

to establish a reference to the use of a target object

0 (unrelated)¼ response shared no features with target act

0 (refusal)¼ no body movement

Conventional gestures: 4 items (8)a

� Waving for greeting

� Shake head for no

� Shrug shoulders for uncertainty

� Fingers to lips for quiet

Object related gestures: 4 items (8)a

Pretend to

� sleep (hands shaping cushion)

� eat with a spoon

� drink from a bottle

� throw a ball

aNumber of items per subtask with max. raw score in parentheses.

6 Autism & Developmental Language Impairments

children and LTs were found on all body movementimitation tasks at T1. An analysis of error patternsshowed that the poorer performance of the LTsample stemmed from higher nonresponse rates andnot from incorrect responses. Evidence from children’scompliance on the instrumental tasks revealed thatnoncompliance was selective, suggesting specific diffi-culty with the body movement imitation tasks ratherthan uncooperativeness (see Dohmen et al., 2013 forfull details). Children in the typically developing andLT groups differed in terms of whether rather thanhow accurately they attempted to imitate body move-ments, in keeping with an almost bimodal distributionof children’s body movement imitation scores at T1with a 10-point gap between the body movement imi-tation scores of 7 and the next score of 17 (minimumscore ¼ 0; maximum score¼ 32; mean¼ 8.41;SD¼ 11.36). Therefore, performance on the T1 bodymovement imitation task was categorised as ‘refusal’or ‘attempt’. A receiver operating characteristics curveanalysis revealed that the optimal cut-off point thatmaximise sensitivity and specificity was between ascore of 1.5 (sensitivity¼ 0.91 and specificity¼ .72)and 2.5 (sensitivity¼ .82 and specificity¼ .78).Accordingly, a body movement imitation score� 2 outof 41 was classified as refusal, a score� 3 as attempt.

Language and social communication. All tests are validated,reliable measures of language and social communica-tion ability in young children and are widely used inclinical practice in Germany.

Language: T1 and T2. At T1, children were assessedwith the Sprachentwicklungstest fur zweijahrige Kinder(SETK-2) (Grimm, Aktas, & Frevert, 2000). TheSETK-2 is a standardised test that was constructed tomeasure children’s general stage of language develop-ment between 24–35 months. It comprises four subteststo assess receptive and expressive language competen-cies: word comprehension, sentence comprehension,word production and sentence production. Childrenwere classified as LTs when they performed at least1.5 SD below average on one subtest and 1.25 SDbelow average on another subtest.

At T2, receptive and expressive language abilities ofthe follow-up sample were assessed on five measuresdrawn from standardised tests:

. The TROG-D (Fox, 2009), the German version ofthe Test for Reception of Grammar (Bishop, 2003),measures the comprehension of sentences of increas-ing complexity.

. The subtests noun and verb production of thePatholinguistische Diagnostik bei Sprach

entwicklungsstorungen (PDSS) (Kauschke &Siegmuller, 2009), in which children are asked toname pictured objects and events, assess expressivevocabulary skills.

. The subtest plural marker of the PDSS elicits themorphological plural marker.

. The subtest sentence repetition of theSprachentwicklungstest fu¡¡r dreijahrige Kinder(SETK-3-5) (Grimm & Aktas, 2001) measures mor-phosyntactic abilities.

Children were classified as having specific languageimpairment when they performed at least 1.5 SD belowaverage on one subtest and 1.25 SD below average onanother subtest. Thus, the same criteria for defininglanguage deficits were applied to participants at T1and T2.

Social communication: T2. Social communicationskills were assessed using the Skala zur Erfassung sozia-ler Reaktivitat (SRS) (Bolte & Poustka, 2008), theGerman version of the Social Responsiveness Scale(Constantino & Gruber, 2005) which has been standar-dised on 1436 German-speaking children. The ratingscale was completed by a parent. It is designed to meas-ure aspects of social interaction in five areas: socialawareness, social cognition, social communication,social motivation and autistic mannerisms. In a clinicalcontext, interpretation is based on a single score reflect-ing the sum of responses to all 65 questions and rawscores are converted to T-values according to genderof child and rater type (parent/teacher) (mean�SDof 50� 10). The SRS manual specifies cut-off scoresfor categories of performance:� 40 high social respon-siveness,� 60 normal social responsiveness,� 61 mildto moderate impairment of social responsiveness,� 76severe impairment of social responsiveness. Childrenwith mild to moderate impairments show social com-munication deficits which are sometimes associatedwith mild ASD, whereas a severe impairment isstrongly associated with a clinical diagnosis of ASD.Based on these categories, children in the follow-upsample were classified as having social communicationimpairments (SCIs) if their T-value was� 61.

Categorical classification on language and social com-

munication: Follow-up sample. At T2, children in thefollow-up sample were classified into four groupsbased on their categorical performance on languageand social communication measures according to thecut-off scores for language impairment and social com-munication impairment described above: language andsocial communication impairment (LI-SCI), languageimpairment only (LI), social communication

Dohmen et al. 7

impairment only (SCI), typical language and commu-nication development (TD) in line with the four-waycategorisation used in Roy and Chiat (2014).

Results

Categorical performance on body movementimitation T1

The number of children who refused the body move-ment imitation task at T1 decreased with age: 61.1% ofchildren in the younger (2;0-2;5: 11of 18) and 45.5% ofchildren in the older (2;6-2;11: 5 of 11) age group wereclassified as refusers.

Categorical outcome on language and socialcommunication T2

Since children in the LT sample at T1 had to fulfill thestudy’s criteria for delayed language development, bydefinition, each participant scored below the chosencut-off on at least two language subtests at that time.At T2, according to the categorical cut-off scores forlanguage and social communication described above,roughly two-thirds of children in the follow-upsample were classified as LI and/or SCI (62%, 18 of29 children), including 31% (9) with LI-SCI; 21% (6)

with LI only; and 10% (3) with SCI only, with theremaining one-third classified as TD (38%, 11of 29).Half of the 2;0–2;5 group emerged as TD (nine of18), compared with only a fifth of the 2;6–2;11 group(18.2%, two of 11). A Fisher’s exact two-tailed testrevealed that the percentage in the younger group washigher, but not significantly so (p¼ .13). Data for the 2-year-olds (n¼ 29) were grouped together to have a largeenough sample for quantitative analysis. No child wasidentified with a severe impairment of social communi-cation (score� 76 on the SRS), indicative of an ASDdiagnosis, nor had any child received an independentclinical diagnosis of ASD.

Associations between T1 predictor and T2outcome measures using continuous scores

Table 3 provides descriptive statistics for continuousscores on T1 body movement imitation and languagepredictor measures, and for continuous scores on T2social communication and language outcome measures.Language composites were created by summing T-scores of all language subtests and dividing the sumby the number of measures.

Spearman’s rho correlations were used to assess thestrength of relations between continuous scores onT1 predictor and T2 outcome measures. In line with

Table 3. Continuous scores on body movement imitation (max¼ 41), language predictor measures and language and social com-

munication outcome measures (n¼ 29).

Time 1

Measure BMI compositea SETK-2 WCb SETK-2 SCb SETK-2 WPb SETK-2 SPbT1 language

compositeb

Mean 8.41 45.62 43.24 31.86 29.62 37.26

SD 11.36 11.66 13.67 6.86 3.51 6.29

Range 0–32 29–69 26–72 23–50 23–36 24.9–49.3

Time 2

Measure SRS compositec TROG-Db PDSS NPb PDSS VPb PDSS PMb SETK-3-5 SRbT2 language

compositeb

Mean 50.72 47.62 44.66 34.79 43.41 42.83 41.69

SD 13.55 10.31 9.02 14.74 10.85 8.99 8.56

Range 25–73 27–65 20–57 14–62 17–59 20–63 19.0–56.4

n: number of participants.

BMI: body movement imitation; NP: subtest noun production; PDSS: Patholinguistische Diagnostik bei Sprachentwicklungsstorungen; PM: subtest plural

marker; SC: subtest sentence comprehension; SD: standard deviation; SETK-2: Sprachentwicklungstest f8r zweijahrige Kinder; SETK-3-5:

Sprachentwicklungstest f8r dreijahrige Kinder; SP: subtest sentence production; SR: sentence repetition; SRS: German version of the Social

Responsiveness Scale (social communication); TROG–D: German version of the test for reception of Grammar (sentence comprehension); VP:

subtest verb production; WC: subtest word comprehension; WP: subtest word production.aScores are shown as raw scores.bScores are shown as t-scores based on mean� SD of 50� 10.cScores are shown as T-values based on mean� SD of 50 � 10. Scores based on norms of the SRS are scaled with 73 as the highest and 25 as the

lowest score, i.e. low scores are good and high scores are poor.

8 Autism & Developmental Language Impairments

predictions performance on body movement, imitationat T1 was associated with social communication out-come at T2 (r¼�.66; p� .001, 95% CI �.39 to �.83),and performance on language measures at T1 was asso-ciated with language outcomes at T2 (r¼ .62; p� .001,95% CI �.33 to �.80). In contrast, correlations betweenperformance on body movement imitation at T1 andlanguage outcome at T2 (r¼ .29, p¼ .13, 95% CI �.59to .09) and performance on language measures at T1 andsocial communication outcome at T2 (r¼�.28, p¼ .14,95% CI �.59 to .10) were not significant.

Relations between T1 body movementimitation and T2 language and socialcommunication using categorical scores

Table 4 provides a 2� 4 cross-tabulation showing thefrequency distribution of categorical performance onbody movement imitation as a T1 predictor (refusal;attempt) and T2 language and social communicationoutcomes measures (LI-SCI; LI; SCI; TD).

As can be seen in Table 4 at follow-up, typical lan-guage was associated with typical social communication(TD n¼ 11) and impaired language was associated withimpaired social communication (LI-SCI n¼ 9) in morethan two-thirds of participants (n¼ 20, 69%). Fewerchildren were classified with LI only (n¼ 6), and casesof SCI only were rare (n¼ 3). Hence, it appears that atthis young age social communication difficulties fre-quently co-occurred with impaired language.

Turning to the relation between T1 predictor and T2outcome variables, a Fisher’s exact test revealed ahighly significant association between the classificationof body movement imitation at T1 and the profile oflanguage and social communication outcome at T2(p5.001; since more than 20% of cells had an expectedcount less than five, an exact contingency table analysiswas conducted using the web source ‘statistics to use’

(Kirkman, 1996) as recommended by McDonald(2009)).

Outcome profiles of TD were in nine out of 11 cases(81.8%) associated with an attempt at body movementimitation at T1, irrespective of the strength and profileof children’s language delay at age two. In contrast,outcome profiles of SCI with or without co-occurringLI were all associated with refusal on body movementimitation at T1 (12 of 12; 100%). However, categoricalperformance on T1 body movement imitation predicteda third (2/6) only of T2 outcome profiles of LIcorrectly. Hence, performance on body movement imi-tation at T1 seems to be a very good predictor of latersocial communication difficulties but a rather poor pre-dictor of ‘pure’ LIs. However, due to the fact that themajority of children with language problems alsoshowed SCIs, performance on body movement imita-tion at T1 nevertheless predicted almost three quartersof children who presented with language difficulties atT2 (73.3%, 11 of 15).

Logistic regression: Contribution of age,language and body movement imitation at T1for language and social communicationoutcome at T2

This study set out to investigate the hypotheses thatperformance on body movement imitation measuresat T1 would predict social communication and lan-guage outcome at T2 and performance on languagemeasures at T1 language outcome at T2. Analyses sofar have been largely in line with expected relationships.In order to evaluate the separate contributions of chil-dren’s age, continuous body movement imitation andlanguage performance at T1 to categorical languageoutcome and communication outcome at T2, two logis-tic regression analyses for language outcome and socialcommunication outcome were conducted. The threepredictor variables language (T1 language composite,Table 3), body movement imitation (T1 body move-ment imitation composite score, Table 3) and age (T1chronological age in months, Table 1) were entered sim-ultaneously. Results are presented in Table 5. A test ofthe full model against a constant model was statisticallysignificant in both analyses. Nagelkerke’s R2 indicateda strong and moderately strong relationship, respect-ively, between predictors as a set and language (.83)and social communication (.79) outcome.

In the case of language outcome all three predictorvariables added significantly to the amount of changeexplained by the model. The predictor language hasan Odds Ratio (i.e. Exp (b)) of 1.84; the predictorbody movement imitation has an Odds Ratio of 1.35.This indicates that when language scores at T1 are

Table 4. Frequencies for categorical performance (n¼ 29) on

T1 body movement imitation and T2 language and social

communication.

BMI at T1

Language and communication

outcome at T2

LI-SCI LI SCI TD Total

Refusal 9 2 3 2 16

Attempt 0 4 0 9 13

Total 9 6 3 11 29

BMI: body movement imitation; LI: language impairment only; LI-SCI:

language and social communication impairment; SCI: social communica-

tion impairment only; TD: typical language and social communication

development.

Dohmen et al. 9

raised by one unit, participants are 1.84 times morelikely to present with an outcome of typical languagedevelopment at T2, and when body movement imita-tion scores at T1 are raised by one unit, participantsare 1.35 times more likely to have a language out-come of typical language development at T2. TheOdds Ratio value associated with age is 0.40, indicat-ing that for every additional month in age at T1,participants are 0.40 times less likely to have an out-come of typical language development at T2 (i.e. tobe identified with language impairment).

In the case of social communication outcome, onlybody movement imitation made a significant contribu-tion to prediction. The Odds Ratio value associatedwith body movement imitation is 7.47, indicating thatwhen body movement imitation scores at T1 are raisedby one unit, participants are 7.47 times more likely topresent with an outcome of typical social communica-tion outcome at T2, once body movement imitationhad been taken into account. The variables languageand age did not make a statistically significant contri-bution to the model. Results not only confirmed bodymovement imitation as an exclusive and moderatelystrong predictor of later social communication outcomebut in addition revealed a significant contribution ofperformance on body movement imitation to predic-tion of later language outcome.

Discussion

This longitudinal study followed up language andsocial communication outcomes in a sample of 4-year-old children who were identified as LTs at theage of 2;0–2;11. In line with previous findings, 50%of the LTs who were 2;0–2;5 at T1 had moved intothe typical range by age four, whereas only 18% ofthe LTs who were 2;6–2;11 had normalised. This ison par with previous reports that only a subset of chil-dren who were identified as LTs at the age of two con-tinues with language and/or social communication

impairments when they get older (Domsch et al., 2012;Ellis & Thal, 2008; Henrichs et al., 2011; Moyle et al.,2007; Paul & Roth, 2011; Rescorla, 2011; Westerlundet al., 2006). However, the percentage of late bloomersin our study is lower than in most unselected populationstudies, especially when language status was identifiedusing parental questionnaires to measure children’slanguage status (Dale et al., 2003; Henrichs et al.,2011; Zambrana et al., 2014), but consistent with pre-vious reports of language and/or social communicationoutcomes of clinically referred samples (Chiat & Roy,2008; Everitt, Hannaford, & Conti-Ramsden, 2009).This highlights the fact that the actual percentage oflate bloomers seems to be related to specific recruitmentcriteria. At T2, children presented with varied profilesof language and/or social communication outcomes,confirming the heterogeneity of language and socialcommunication skills and deficits observed in childrenwith specific deficits in language. However, results alsohighlighted that at this young age language problemsfrequently co-occurred with social communicationimpairments.

The main aim of this study was to investigate theperformance of LTs on early body movement imitationand language tests as predictors of their later socialcommunication and language outcomes. To the bestof our knowledge, no study has previously addressedthis specific topic. As hypothesised, early languageskills at T1 were predictive of later language outcomeand body movement imitation skills at T1 were predict-ive of later social communication outcome. Findingsfurther revealed that body movement imitation at T1also contributed significantly to the prediction of lan-guage outcome at T2 (i.e. language impairment versustypical language development), whereas language skillsat T1 did not contribute significantly to the predictionof social communication outcome at T2 (i.e. socialcommunication impairments versus typical social com-munication development). Thus, different outcome pro-files were associated with different verbal and nonverbal

Table 5. Logistic regression results for T1 predictors of T2 outcome (n¼ 29); discrete dependent variable: impaired develop-

ment versus typical development.

T2 language

(R2 Nagelkerke¼ .83;

Model �2 [3]¼ 28.37***)

T2 communication

(R2 Nagelkerke¼ .79;

Model �2 [3]¼ 25.84***)

T1 predictors included b (SE) Exp (b) b (SE) Exp (b)

Language composite T1 .611* (.31) 1.84 ns

Body movement imitation T1 .297* (.14) 1.35 2.01* (.94) 7.47

Age T1 �.897* (.39) .40 ns

Note. * p5.05., ** p5.01., *** p� .001., ns¼ nonsignificant; Exp (b) or Odds Ratio is the indicator of the change in odds resulting from a unit change in

the predictor. If the value exceeds 1 then the odds of an outcome occurring increase; if the figure is less than 1, any increase in the predictor leads to a

drop in the odds of the outcome occurring.

10 Autism & Developmental Language Impairments

predictor variables. Results highlight the need to theor-etically and clinically account for the heterogeneity ofdifferent language and communication trajectories inLTs. The current study confirms the need for futurestudies to look in more depth at specific sociocognitiveand nonverbal communication abilities as predictorand outcome variable to understand more about thenature of early sociocognitive and communicationproblems and putative selective relations to laterlanguage and/or communication deficits in childrenwith delayed language emergence, rather than focusexclusively on language skills (Chiat & Roy, 2013;Roy & Chiat, 2014). Outcomes also emphasised thenecessity to define and measure sociocognitive and/ornonverbal communication variables with the same pre-cision as one would expect when addressing languageskills.

The finding that body movement imitation at T1, asa measure of sociocognitive capacities, is a unique pre-dictor of later social communication outcome is in linewith the sociocognitive hypothesis of the mappingtheory (Chiat, 2001; Chiat & Roy, 2008) that earlysociocognitive difficulties will affect the developmentaltrajectories of language and social communication. It isalso consistent with results reported by Chiat andRoy (2008), who identified a measure of social respon-siveness, joint attention and symbolic understanding aspredictive of later social communication skills in asample of toddlers who were referred to speech andlanguage therapy services.

The finding that body movement imitation at T1contributed to prediction of later language outcome isin line with findings of studies reported in the‘Introduction’ section, which highlighted early socio-cognitive and nonverbal communication behavioursas promising predictors of children’s language trajec-tories (Pesco & O’Neill, 2012; Thal et al., 1991;Zambrana et al., 2014). It also reinforces the case formultifactorial predictive risk models for later languageoutcome that consider a range of verbal and nonverbalfactors (Desmarais et al., 2008; Ellis & Thal, 2008).

Limitations

In this study, we argue that difficulties with elicitedbody movement imitation may provide a windowonto sociocognitive abilities since nonverbal imitationskills are assumed to rely significantly on sociocogni-tive abilities (Carpenter et al., 2002; Tomasello &Carpenter, 2005). A limitation is that no additionalmeasures of social cognition were given at T1 (otherthan body movement imitation) in this study, andthus the body movement imitation’s concurrent val-idity with other social cognition measures can only behypothesised. Further, results in this study are based

on a rather small sample of participants and accord-ingly have to be interpreted with caution.

Conclusion

Imitation behaviour is multifaceted and a range ofcompetencies are thought to be involved (Rogers &Williams, 2006). The nature of different imitation actsvaries substantially, and not all competencies are neces-sarily involved in the same way for all types of imita-tion. The body movement imitation task reported inthis paper seems to tap one or more specific competen-cies which appear to be particularly challenging for agroup of children with delayed language emergence andare likely to be linked to skills underlying language andsocial communication acquisition. These competenciesare required for the immediate elicited imitation ofbody movements in a particular setting. We wouldnot assume children to show the same difficulties indifferent imitation tasks, e.g. spontaneous body move-ment imitation in a familiar environment or the imita-tion of actions on objects. This is supported by ourfinding of the initial phase of this study at T1 thatrefusal to imitate action on objects occurred only occa-sionally in the LT group and no child refused all itemsof this task (Dohmen et al., 2013). Results show that alarge percentage of children in the LT group refused toimitate body movements. Based on the mappingtheory, and on empirical evidence from research withtypically developing children and children with ASD weargued that difficulties with body movement imitationmay be indicative of sociocognitive deficits and that theability to establish a sense of connectedness with thedemonstrator is at the core of the imitation difficultiesobserved in the LT sample (Dohmen et al., 2013).However, at this stage of research and within the con-text of this paper it remains speculative what the refusalto comply with our body movement imitation taskactually means. In addition, there might be the concernthat refusal versus attempt to perform on the bodymovement imitation measure is a rather macro-level‘marker’ of social cognition. Future research includingindependent measures of different sociocognitive skills,levels of anxiety and temperament is needed to bring tolight possible explanations for children’s refusal to imi-tate body movements. This might clarify the findingthat body movement imitation was a poor predictorof ‘pure’ language impairment, which was in line withfindings on predictiveness of the Early SociocognitiveBattery reported in Roy and Chiat (2014). But despitethis need for further research to find out why the bodymovement imitation task is predictive of children’s laterlanguage and communication outcomes, it is importantto acknowledge that this measure is predictive. In thefuture it might therefore have the potential to improve

Dohmen et al. 11

the identification of the subset of pre-schoolers withlate language emergence who are at risk to presentwith clinically significant social communication andlanguage problems when they get older. Poor categor-ical performance on the body movement imitation task(i.e. refusal to imitate) might help to detect childrenwith later social communication deficits and contributeto the detection of children who are at risk to presentwith persistent language impairments. In contrast, ade-quate categorical performance on the body movementimitation task (i.e. attempt to imitate) might serve asone indication for a positive prognosis, since the major-ity of LTs who attempted body movement imitation atT1 moved into the typical range on social communica-tion and language assessments at T2. The administra-tion of the body movement imitation task is quick, easyand requires no additional material and would there-fore be suitable as part of a larger screening tool. In thecontext of a screening tool, a macro-level task couldeven be seen as an advantage. However, the need forreplicating results of this study with a larger number ofparticipants is emphasised before we find out whether abody movement imitation task has the potential to pro-vide clinicians with additional information about whichLTs would benefit from early intervention services.

Acknowledgements

We are extremely grateful to the families who gave generouslyof their time to make this study possible.

Authors’ contributions

AD designed the study, carried out recruitment and assess-ment of children, analysed the data, and wrote the first draftof the manuscript. DVMB, SC and PR advised on designing

the study, analysing data and writing-up of the manuscript.All authors discussed, read and approved the finalmanuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest withrespect to the research, authorship, and/or publication of thisarticle.

Funding

The author(s) disclosed receipt of the following financial sup-port for the research, authorship, and/or publication of thisarticle: This work was funded by the Economic and SocialResearch Council (ES/J001961/1) and the Wellcome Trust

(082498/Z/07/Z).

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Author Biographies

Andrea Dohmen is a Professor of Speech and LanguageTherapy at the Hochschule fur Gesundheit inGermany. She trained and practised as a speech andlanguage therapist, before then completing an MSc(University College London) and a PhD (CityUniversity London) in Language and CommunicationScience in the UK. From 2012-2016 she has worked asa postdoctoral researcher and member of the OxfordStudy of Children’s Communication Research Group(OSCCI) at the University of Oxford (2012-2016).Her interdisciplinary research focuses on typical andatypical language and communication developmentand is concerned with the early identification and inter-vention of language and communication difficulties inchildren.

Dorothy VM Bishop, FBA, FMedSci, FRS is aWellcome Trust Principal Research Fellow andProfessor of Developmental Neuropsychology at theUniversity of Oxford, where she heads a programmeof research into children’s communication impair-ments. She is a supernumerary fellow of St John’sCollege Oxford. Her main interests are in the natureand causes of developmental language impairments,with a particular focus on psycholinguistics, neurobiol-ogy and genetics. She also is active in the field of openscience and research reproducibility.

Shula Chiat BA, PhD, is a psycholinguist specialising intypical and atypical language development. She hasworked at City University London (1982–2000, 2006to date) and at University College London (2000–2005). Her current research and research supervisionfocus on early assessment and identification of childrenat risk of language and social communication impair-ments, the development of cross-linguistic assessments,the theoretical and clinical implications of nonwordand sentence repetition tasks, and evaluation of inter-ventions motivated by theoretical and empiricalevidence.

14 Autism & Developmental Language Impairments

Penny Roy, BSc, MSc, PhD, Cert Ed Psych, is anHonorary Professor of Developmental Psychology atCity University. She has a particular interest in theeffects of early socioeconomic disadvantage and deaf-ness on language, literacy and psychosocial

development. Her collaborative research includes thedevelopment of preschool assessments of languageand sociocognitive skills.

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