ISSN (Online) Commun Sci Disord 2016;21(3): Original Article A Meta-analysis of Children s Commu

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1 ISSN (Online) Commun Sci Disord 2016;21(3): Original Article A Meta-analysis of Children s Communication Checklist (CCC) for Children & Adolescents with Pragmatic Language Impairment Seungha Song, Yoonhee Yang, Young Tae Kim, Dongsun Yim Department of Communication Disorders, Ewha Womans University, Seoul, Korea Correspondence: Young Tae Kim, PhD Department of Communication Disorders, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea Tel: Fax: youngtae@ewha.ac.kr Received: February 12, 2016 Revised: May 16, 2016 Accepted: May 25, 2016 This work was supported by the Ministry of Education of Korea and the National Research Foundation of Korea (NRF-2015S1A5A2A ). This work was supported by BK21 PLUS Project by the Korean Government. Objectives: Children and adolescents with pragmatic impairment show overall communication problems. However, the pragmatic problems vary depending on their diagnostic characteristics. The Children s Communication Checklist (CCC, CCC-2) was developed to assess overall ability through parents and/or teacher s reports (Bishop, 2003). This research reviews studies of pragmatic assessment using CCC or CCC- 2, and investigates if children and adolescents with pragmatic deficits (autism spectrum disorders [ASD], attention deficit/hyperactivity disorders [ADHD], and Williams syndrome [WS]) can be differentiated through CCC or CCC-2. Methods: Fourteen studies which met the inclusive and exclusive criteria were selected from three electronic databases: PsycINFO, Academic Search Complete, and ERIC. A systematic review was done using meta-analysis (Comprehensive Meta-Analysis II, 2005). Results: There was a significant group difference between ASD and ADHD showing significant differences with typically development (TD), respectively, but there was no difference between the WS and TD controls. The sub-domains (structural/pragmatic/autism-social domain) that brought group differences were all three sub-domains in the ASD group. Structural and pragmatic domains were significantly different sub-domains in the ADHD group. Conclusion: CCC or CCC-2 is a useful tool for discriminating ASD and ADHD groups from TD controls. However, it is not enough to represent various pragmatic profiles depending on diagnostic groups such as ASD and ADHD. Therefore, it is necessary to use both direct and indirect assessment tools to reveal the differential profiles of pragmatic problems in various groups with communication disorders. Keywords: Children s Communication Checklist, Autism spectrum disorder, Attention deficit/hyperactivity disorders, Williams syndrome, Meta-analysis 의사소통 이란, 나 의생각과감정을 타인 과서로주고받는것으로, 바람직한의사소통이이루어지기위해서는언어규칙그자체에대한지식을습득해야할뿐만아니라상호적인의사소통맥락에서사회구성원들에게합의된방법으로적절하게사용되어야한다. 의사소통장애 는의사소통능력에결함이있어타인과의의사소통에어려움을겪는것을말한다. 이경우개인의교육, 직업, 삶의질에매우심각한영향을미치게되며, 의사소통상의소외는다양한삶의맥락에서의불이익가능성을내포한다 (Sim, 2010). 따라서인간의삶에서의사소통능력은필수불가결한매우중요한 요소로간주된다. 의사소통및언어능력가운데 화용능력 은언어지식에기초하여사회적지식이의사소통맥락에서발휘될때드러나며, 화자가자신의언어사용을지속적으로살피고점검하는능력을포함한다 (Phelps-Terasaki & Phelps-Gunn, 2007). 즉, 화용은사회적상황과의사소통맥락에적절한언어를사용할수있는능력이다 (Bates, 1976). 화용결함이나타나지않는비장애아동의경우목적과문맥에적절하게언어를사용하고다른사람의의도를이해하는화용론적능력을언어이전기또는발달초기에이미습득하게된다 Copyright 2016 Korean Academy of Speech-Language Pathology and Audiology This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 아동의사소통체크리스트 (CCC) 를활용한화용언어장애아동의의사소통능력평가에대한메타분석 송승하외 (Kim, 2014). 화용능력을독립적으로평가하는도구는상대적으로그수가적은편이고, 특히한국어사용자를대상으로한화용평가도구는주로간접적인평가에의존하고있다. 영어사용자를대상으로한화용평가도구는검사지를통한직접또는관찰평가와부모및양육자를통한설문지나체크리스트형식의간접평가로크게나뉜다. 직접또는관찰평가는대체로만 4-18세를대상으로하며, 간접평가는대체로유아기부터성인기까지대상연령의폭이넓다 (Norbury, Nash, Baird, & Bishop, 2004; Phelps-Terasaki & Phelps-Gunn, 2007). 구조화된직접평가도구로는 Test of Pragmatic Language-2 (TOPL-2; Phelps-Terasaki & Phelps-Gunn, 2007) 가대표적이다. TOPL-2 는만 6-18세의구어사용이가능한아동및청소년을대상으로실시하는직접평가이다. TOPL-2 는 Norris와 Hoffman (1993) 의상황-담화-의미 (Situational-Discourse-Semantic, S-D-S) 모델을응용하여, 검사하위영역을상황 ( 물리적맥락과청자 ), 담화 ( 주제, 목적 ), 그리고의미 ( 시각-제스처단서, 추상적개념, 화용평가 ) 로구성하였다. 평가결과는백분위수와등가연령및등가학령으로환산가능하고, 인지능력검사에서흔히제시되는화용언어표준점수를제공한다 (Phelps-Terasaki & Phelps-Gunn, 2007). 그밖에도 Clinical Evaluation of Language Fundamentals (CELF) 와같은종합언어검사의하위검사로화용평가가가능하다. 또한 Yale in vivo Pragmatic Protocol (YiPP; Simmons, 2013) 과같이반구조화된 (semi-structured) 상황에서의평가도개발되어있다. 특히 YiPP 은구조화된직접검사에서그한계로지적되고있는자연스러운상황을일관되게제시하여평가한다는점에서대안이되기도한다. 그러나현실적으로언어치료실에서이루어지는의사소통능력평가상황에서는아동의의미있는화용언어능력을평가하는것에는한계가있다. 물리적인변화가능성을비롯하여대화상대자또한평가자또는양육자로국한되기때문이다. 특히, 화용언어는문맥의존적인특성을지니기때문에구조화된공식적검사절차속에서는변화하는환경에유연하게조정하는아동의능력들을세심하게끌어내는데에어려움을겪게된다 (Adams, 2002). 뿐만아니라, 화용결함이있는아동들은공식적검사절차상황과같은구체적으로주어지는문맥내에서명확한지시사항이주어질경우평소보다더좋은수행을보이는경향이있기때문에자연스러운상황에서두드러지는이아동들의화용결함을충분히확인하는데에한계점을보인다 (Bishop & Adams, 1989). 이에따라아동에대해잘알고있는부모또는주양육자보고형식의체크리스트검사가대안으로제시될수있다. 부모또는주양육자의보고는가정내에서관찰되는아동의가장자연스러운언어사용에대해평가 가가능하며, 아동을잘아는사람에의해보고되기때문에시시각각변화할수있는아동의컨디션에영향을덜받는다. 뿐만아니라상대적으로적은시간이소요되어임상현장에서도효율적인도구로활용가능하며, 구조화된공식적검사상황에서이끌어내기어렵거나, 발생빈도가낮은행동에대해평가할수있다는장점을지닌다 (Bishop, 1998). Children s Communication Checklist (CCC; Bishop, 1998) 는아동과정기적으로접촉하는성인또는부모의판단에의해임상적으로유의한의사소통문제를선별해내고화용언어결함을확인하기위해고안되었다 (Volden & Phillips 2010). 이평가도구는의사소통의질적인측면에서어려움을보이는아동들을평가하기위한도구로, 전반적인의사소통결함을선별할뿐만아니라, 대부분의전통적언어검사들이다루지않고있는화용의사소통평가도포함하고있다 (Bishop, 1998). 이검사는특히자폐범주성장애 (autism spectrum disorder, ASD) 집단이지니는임상적으로유의한화용결함을광범위하게다루고있어, 이들의화용결함을확인하는데에매우효과적이다. CCC (Bishop, 1998) 또는 CCC-2 (Bishop, 2003) 는비장애아동으로부터전반적인의사소통상의어려움을보이는아동을선별해내는데에도매우효과적일뿐만아니라 ASD를포함하여다양한장애집단간비교를가능하게해주는도구이다. Geurts, Verté, Oosterlaan, Roeyers 그리고 Sergeant (2004) 의연구에서도고기능 ASD와비장애아동집단을구별해내는데에매우효과적임을입증하였다. ASD 아동은어휘, 구문지식, 음운, 형태론적영역에서결함을보일지라도, 주된결함은언어의화용양상에서두드러지게나타난다 (Lord & Paul, 1997). 즉, 화용결함은일생을지속하는반면다른언어와관련된어려움들은자라면서더이상드러나지않기도한다 (Rapin & Dunn, 2003). 즉, 어휘, 의미, 문법과같은언어능력은아동이성숙함에따라갖춰질수있다고하더라도화용언어상의어려움은연령이증가하더라도계속적으로존재하기때문에이집단에서의특징적인화용언어의손상에많은연구자들이지속적으로동의해왔으며이영역에대한연구또한집중적으로이루어지고있다 (Landa, Accardo, Magnusen, & Capute, 2000; Tager-Flusberg, Paul, & Lord, 2005; Young, Diehl, Morris, Hyman, & Bennetto, 2005). 또한 ASD의진단적기준에따르면, 이들은사회적의사소통기술의결함을보이며, 제한되고반복적인관심을지니는특징을보인다. ASD 아동의세부적인화용상의어려움은 대화시작하기, 다른사람의주도에반응하기, 적절하게대화를주고받기 등에서나타난다 (Baron-Cohen, 1988; Botting & Conti-Ramsden, 2003; 437

3 Seungha Song, et al. Meta-analysis of Children s Communication Checklist Curcio & Paccia, 1987; Prizant & Rydell, 1984; Stone & Caro-Martinez, 1990; Tager-Flusberg, 1996). 특히, 주제를유지하고관련된정보로대화를발전시키는것에서도유의한어려움을보이는데, ASD 아동은이전에언급했던주제를계속말하거나이전에언급한것과관련된주제어로연결짓는것에실패를보인다 (Volden, 2002; Choi & Lee, 2013, 2015). 이들의대화는관련없는것을포함하거나, 부적절하거나, 틀에박힌표현이특징적이다 (Adams, 2002; Gilchrist et al., 2001; Volden, 2004). 이들은또한 CCC의하위영역중에서는부적절한시작 (inappropriate initiation), 응집력 (coherence), 정형화된언어 (stereotyped ), 문맥사용 (use of context), 그리고라포 (rapport) 형성과같은화용적인측면에서특히유의하게어려움을보이는것으로보고된바있다 (Bishop & Baird, 2001; Geurts et al., 2004; Verté et al., 2006). 사회의사소통또는화용에서의결함을보이는또하나의주요집단으로주의력결핍과잉행동장애 (attention-deficit/hyperactivity disorder, ADHD) 집단이있다. 이들은사회적기술을습득하고효율적으로활용하는데에어려움을보이며, 언어의사회적사용 (Prutting & Kittchner, 1987) 과같은언어적인어려움역시이들에게흔하게나타난다 (Staikova, Gomes, Tartter, McCabe, & Halperin, 2013). 이아동들의사회적어려움은충동성으로인한차례기다리기, 부주의함으로인한상대방의말경청하기 (Barkley, 1997) 등에서어려움을보이며, 이들의화용결함은사회적지식의부족 (Grenell, Glass, & Katz, 1987), 신경심리학적원인 (Barkley, 1997; Huang-Pollock, Mikami, Pfiffner, & McBurnett, 2009), 그리고사회적정보처리결함 (Crick & Dodge, 1994) 으로부터비롯된다고보기도하였다. ADHD 아동은특히집행기능상에서의어려움이두드러지게보고되고있는데, 이와관련하여특히억제 (inhibition) 에서의결함으로인해충분한계획이없이말을시작하는경향이있으며, 조음도중말을유예하는등언어산출에서의효율도부족한것으로나타난다 (Engelhardt, Corley, Nigg, & Ferreira, 2010; Engelhardt, Ferreira, & Nigg, 2011). 한편, 화용영역의결함을보이는또하나의집단으로는 7번염색체결함으로발생하는윌리엄스증후군 (Williams syndrome, WS) 이있다. 이들은상대적으로언어에서의강점을나타내지만화용언어의문제는지속적으로보고되고있다 (Mervis & Klein-Tasman, 2000; Semel & Rosner, 2003; Strømme, Bjømstad, & Ramstad, 2002). 일반적으로인지적인장애를동반하는 WS의경우, 타인에대한높은관심과공감능력을지님에도불구하고, 또래관계형성및유지에어려움을보인다고보고하였다 (Jones et al., 2000; Semel & Rosner, 2003; Tager-Flusberg & Sullivan, 2000). 즉, 표면적으로 ASD가사회성에결함이있다면 WS는오히려과도한사회성을지니는것으로, 상반되는표현형을지니지만화용언어상의어려움은두집단모두지니고있다고볼수있다 (Philofsky, Fidler, & Hepburn, 2007). 이들은얼굴표정에대한모방또한가능하여상대적으로사회적관계에서도강점을지닐것으로보이기도하지만, 지나치게말을많이하고, 배운표현을필요이상으로사용하며, 같은질문을여러번반복하는등의과도함이이집단에서의화용적인쟁점이라할수있다 (Philofsky et al., 2007). 이처럼공통적으로화용능력을포함한의사소통상의어려움을보이는것으로확인된 ASD, ADHD, 그리고 WS 집단은 CCC를통해언어구조, 화용, 자폐-사회성으로구성된 3가지하위영역에따라비장애아동집단과구별되는특징적인프로파일을보일수있다. 이는또한각장애집단간에도진단적특성과맞물려세부적으로공통적인어려움을보이거나또는차별적인어려움을나타낼것으로예상된다. 최근에는국내에서도 CCC와관련된화용검사도구에대한연구및화용평가에대한필요성에대한논의가활발히진행되고있다. Lee (2010) 는국외화용언어평가도구들을분석하여국내에서도유용하게활용될수있는화용언어능력평가도구개발의필요성을언급하였다. 이에 Oh, Lee와 Kim (2012) 은 아동화용능력체크리스트 문항개발을위한예비연구로주제관리, 상황에따른조절과적용, 의사소통의도, 비언어적의사소통의네가지하위영역을통해국내현실에적합한문항및검사절차를개발하였으며, 이연구를통해 ASD 아동의수행이언어지연, 지적장애및기타장애아동들과비슷한프로파일을보였으나전반적인수행력이두드러지게낮았음을보고하였다. Seo와 Ahn (2015) 은지금까지언어의형식및구조적인특성에대해서만중점적으로다루었던의사소통능력에대한평가와더불어화용결함도함께살펴볼수있어넓은의미에서의의사소통능력을평가할수있는아동용의사소통체크리스트 (CCC, CCC-2) 의유용성을확인하였다. CCC는화용언어능력및의사소통능력에서의결함유무를확인할수있을뿐만아니라, 언어구조, 화용, 사회성의각하위영역별강약점을살펴볼수있다는장점이있음을언급하였다. 또한연구결과를통해단순언어장애, 자폐성장애, 일반아동집단을대상으로각집단이분류되는정확도는 76.8% 로나타나 CCC가우리나라아동들에게도적용하기에유용한도구임을입증하였다. 그러나, 주로화용결함이나타난다고보고된 ASD, ADHD, 그리고 WS 세집단을모두연구대상으로포함하여실시된국내외연구들은부족한실정이므로이들집단의일부또는전체를대상으로한연구결과들을함께통합하여고찰해볼필요성이제기된다

4 아동의사소통체크리스트 (CCC) 를활용한화용언어장애아동의의사소통능력평가에대한메타분석 송승하외 따라서본연구는화용결함이있는것으로보고되는 ASD, ADHD, 그리고 WS 세집단을대상으로최근들어가장널리사용되는부모보고형태의화용평가도구인 CCC 또는 CCC-2를활용한연구들을고찰하고, 통제집단인비장애집단과의차이를분석하고자하였다. 또한 ASD, ADHD, 그리고 WS 각집단의의사소통및화용결함은과소또는과잉표현형, 내적지식의부족, 외적활용능력등에서다양한원인및결과로나타날수있는특성에따라 CCC의세가지하위영역 ( 언어구조, 화용, 자폐-사회성 ) 중어떤영역에서의미있는차이를보이는지를분석하고자하였다. 이에따른연구문제는아래와같다. 1. 화용언어장애집단 (ASD, ADHD, WS) 과비장애집단은 CCC 결과를통해유의한차이를보이는가? 1) ASD와비장애집단은 CCC 결과를통해유의한차이를보이는가? 2) ADHD와비장애집단은 CCC 결과를통해유의한차이를보이는가? 3) WS와비장애집단은 CCC 결과를통해유의한차이를보이는가? 논문의선정기준 PsycINFO에서 28편, Academic Search Complete에서 92편, ERIC에서 118편으로총 238편의연구가검색되었다. 논문의선정기준 ( 예 : scholarly journals; Language, English) 및제외기준을통해최종 14편의문헌을선정하였다. 포함기준은 (1) 학술논문으로전문 (full-text) 이제공되어야하고, (2) CCC-2 (Bishop, 2003) 가개정된 2003년이후부터현재까지출판된논문들을대상으로, (3) 언어는 영어 로, (4) ASD, ADHD, WS 그리고통제집단인비장애집단을대상으로하며, (5) CCC 및 CCC-2의점수에대해평균및표준편차가명시된논문을포함하였다. 제외기준은 (1) 학술논문으로전문 (full-text) 이제공되지않은논문, (2) CCC-2 (Bishop, 2003) 가개정되기이전인 2003년이전에출판된논문, (3) 언어가 영어 가아닌경우, (4) 대상자가본연구의화용언어장애집단인 ASD, ADHD, 그리고 WS 집단이아닌경우, (5) 그리고 CCC 및 CCC-2 의수행점수 ( 평균및표준편차 ) 가제시되어있지않아서조건을충족시키지못하는경우분석대상에서제외하였다. 논문선정과정은 Figure 1과같으며, 선정된개별논문의특성은 Table 1에요약하여제시하였다. 2. 통제집단인비장애집단과유의한차이를보인집단 (ASD, ADHD) 의경우, CCC의하위영역 ( 언어구조, 화용, 자폐-사회성 ) 중그룹간유의한차이를불러일으키는세부영역은무엇인가? 1) ASD와비장애집단간유의한차이를불러일으키는 CCC 의하위영역은무엇인가? 2) ADHD와비장애집단간유의한차이를불러일으키는 CCC 의하위영역은무엇인가? 연구방법문헌검색방법 CCC를통해의사소통장애집단과비장애집단의화용능력의차이를알아보기위해 2015년 11월에 PsycINFO, Academic Search Complete, ERIC 데이터베이스에서문헌검색을실시하였다. 문헌수집에사용된검색어로 pragmatic assessment, PLI, ADHD, 또는 Children s Communication Checklist, CCC, CCC- 2 를사용하였다. 특히 ERIC 데이터베이스에서는 CCC 외의다른화용검사에대한결과를다수포함하였으므로, 과제관련검색어에 Children s Communication Checklist 로한정하여재검색한결과, 3건의논문이추가적으로포함되었다. 신뢰도평가 언어병리학박사과정연구자 2 인은전체분석논문에해당되는 14 편의연구를코딩하여효과크기를산출하고, 각항목별로일치 한수의비율을측정한결과, 일치율은 100% 였다. Total 238 searched PsycINFO (N=28) Academic Search Complete (N=92) ERIC (N=118) [Inclusion criteria] 1. Scholarly journals (full text) present 3. Language: English 4. Participants: ASD, ADHD, WS and control group (TD), specified diagnostic criteria 5. Methods & Results: mean & standard deviation of CCC score in groups Eligible articles (N=13) [Exclusion criteria] 1. Full text unavailable 2. Before Language: Not English 4. Participants: unspecified diagnostic criteria or multiple disability 5. Methods & Results: No CCC score or only effect size provided Figure 1. Flowchart of studies included from database searching. ASD= autism spectrum disorder; ADHD= attention deficit/hyperactivity disorders; WS= Williams syndrome; TD = typically development; CCC = Children s Communication Checklist

5 Seungha Song, et al. Meta-analysis of Children s Communication Checklist Table 1. Summary of studies included in the meta-analysis No. Study Statistical analysis 1 Volden & Phillips (2010) 2 Helland et al. (2010) 3 Geurts & Embrechts (2008) 4 Helland et al. (2012) Participants (N) Variable Clinical population Controls Independent Dependent One-way ANOVA 6-10 yr ASD (16) 6-10 yr TD (16) 2 (group) CCC-2 CELF-4 TOPL MANOVA 6-15 yr ADHD (28) 6-15 yr AS (19) Study 1: MANOVA 7-14 yr ASD (26) 7-14 yr ADHD (29) Study 2: MANOVA, multiple regression One-way ANOVA, nonparametric test(mann-whitney U), effect size 5 Timler (2014) Descriptive statistics, F tests, effect size, bivariate correlation 6 Sadiq et al. (2012) One-way ANOVA, chi-square tests 7 Norbury et al. (2004) 8 Grzadzinski et al. (2011) Study 1: One-way ANOVA Study 2: One-way ANOVA ANCOVA (covarying for age and sex), chi-square tests 4-7 yr ASD (28) 4-7 yr SLI (28) 6-12 yr SLI (19) 6-12 yr ADHD (21) 6-15 yr TD (28) 3 (group) pragmatic 7-14 yr TD (29) 3 (group) pragmatic 4-7 yr TD (28) 3 (group) pragmatic 6-12 yr TD (19) 3 (group) pragmatic Study results The CCC-2 identified 13 of the 16 children with ASD as pragmatically impaired, while the TOPL identified only 9. Neither test identified any of the children in the control group as having pragmatic impairment. CCC-2 Communication impairments were as common in a group of children with ADHD as in a group of children with AS. Although a similar pattern appeared on most CCC-2 scales, children with ADHD and AS could be distinguished from each other in terms of their profiles on the subscales assessing stereotyped and nonverbal communication. CCC-2 The first study indicated that school aged children with ASD have similar profiles to children with ADHD. Both groups had relatively more difficulty with pragmatics CCC-2 than with structural aspects. The second study indicated that both PBQ preschoolers with ASD and those with SLI show the opposite pattern, thus having CCC-2 SDQ 5-7 yr ADHD (32) 5-8 yr TD (12) 2 (group) CCC-2, CELF-4 TNL 5-8 yr RAD (35) 5-8 yr ASD (52) 4-17 yr SLI (19) 4-17 yr PLI (14) 4-17 yr PLI+ (21) 4-17 yr HFA (17) 4-17 yr ASP (16) 6-10 yr SLI (15) 6-10 yr PDDNOS (10) 6-10 yr HFA (19) 6-10 yr ASP (7) 7-17 yr ADHD (51) 7-17 yr ADHD+ (24) 5-8 yr TD (39) 3 (group) pragmatic 4-17 yr TD (21) 5 (group) pragmatic None 4 (group) pragmatic 7-17 yr TD (69) 3 (group) pragmatic CCC-2 ADI-R relatively more difficulty with structural aspects than with pragmatics. Communication impairments were as prominent in the ADHD group as in the SLI group. However, the groups were separable form each other in terms of their profiles. Furthermore, the ADHD group experienced significantly more mental health problems compared with the SLI group. CCC-2 GCC scores correctly classified 10 participants with ADHD diagnosed with LI as defined by composite scores 85 on the CELF or TNL. Severity and specificity rates were 100% and 85.29%, respectively. CCC-2 scores and most measures were significantly correlated. The RAD group demonstrated significant problems in their use of context, rapport, and social relationships with a degree of severity equivalent to children with ASD. More than 60% of the group with RAD met ADI-R clinical criteria on the use of and other social communication subscales. The RADs appear to be at least as impaired as children with ASD in certain domains of social relatedness, particularly in their pragmatic skills. CCC-2 The CCC-2 distinguished children with communication impairments from non-impaired peers. Furthermore, the SIDC identified children with disproportionate pragmatic and social difficulties in relation to their structural impairments. This measure also had good interacted agreement (r=.79). CPRS-R:L CBCL CCC-2 ADHD+ and ADHD subgroups differed significantly in CCC-2 pragmatic and autistic/ social domains. (Continued to the next page) 440

6 아동의사소통체크리스트 (CCC) 를활용한화용언어장애아동의의사소통능력평가에대한메타분석 송승하외 Table 1. Continued Participants (N) Variable Study results No. Study Statistical analysis Clinical population Controls Independent Dependent CCC-2 According to the CCC-2 questionnaire, differences between the groups were found in linguistic abilities, pragmatics skills, and social interaction yr ADHD (19) 5-8 yr TD (19) 2 (group) pragmatic Nonparametric test (Mann-Whitney U) 9 Väisänen et al. (2014) CCC-2 The GCC revealed that the scores for the children in the BP(the group with behavior problems) group were significantly lower than the scores for the control group yr ADHD (40) yr TD (37) 2 (group) pragmatic Independent-samples t-tests 10 Helland et al. (2014) Children with HFA, AS, and PDDNOS showed pragmatic communication deficits in comparison to the controls. Little difference was found between the three subtypes with respect to their CCC profile. ADI-R CCC 6-13 yr TD (47) 4 (group) pragmatic 6-13 yr HFA (57) 6-13 yr AS (47) 6-13 yr PDDNOS (31) ANOVA (post-hoc Bonferroni) 11 Verté et al. (2006) CCC Compared to NC, children with HFA showed pragmatic deficits on all CCC scales. Children with ADHD demonstrated deficits compared to NC as well. Moreover, the ADHD and HFA groups differed from each other on most of the scales yr TD (35) 3 (group) pragmatic One-way ANOVA 5-14 yr HFA (42) 5-14 yr ADHD (23) 12 Guerts et al. (2004) CCC Checklist ratings for the group with WS indicated significant levels of pragmatic impairment, and difficulties with social relationships yr TD (32) 4 (group) pragmatic 6-25 yr WS (19) 6-25 yr DS (24) 6-25 yr SLI (17) One-way ANOVA (post-hoc Scheffe) 13 Laws & Bishop (2003) CCC-2 ASD and WS groups demonstrated impairment in overall communication and pragmatic functioning, but children with WS performed significantly better on overall pragmatic functioning, and the magnitude of the effect was medium yr TD (19) 3 (group) pragmatic MANCOVA 7-12 yr ASD (20) 6-12 yr WS (21) 14 Philofsky et al. (2007) ASD = autism spectrum disorder; ADHD = attention-deficit/hyperactivity disorder; AS = Asperger syndrome; HFA = high functioning autism; WS = Williams syndrome; CCC = Children's Communication Checklist. 자료의분석자료의코딩연구자, 게재연도, 연구내대상아동의장애유형 (ASD, ADHD, WS), CCC 하위영역, 통제집단및실험집단의표본크기등을데이터로입력하였다. 독립변인은집단과 CCC의세부하위항목이며, 종속변인은세부하위항목별점수이다. 이에따라평균및표준편차와같은통계치를코딩하였다. 출판편향검증 출판편향 은출간된연구결과가모든연구의결과를충분히대표하지못하는것으로, 연구결과의속성이나방향에따라연구결과가출간되거나출간되지못하는오류를의미한다 (Higgins & Green, 2011). 이에따라메타분석시이미출판된학술저널에서의결과를데이터로분석할경우출판편향의위험성을보고해야할필요성이제기된다. 출판오류가어느정도이며전반적인연구결과가신빙성이있는지확인하기위해 Classical fail-safe N (Rosenthal, 1979) 계수를산출하였다. 그결과, 210으로 5K ( 연구수 =13)+10 = 75 보다크면신빙성이있는수치이므로, 본연구는출판편향의영향이유의하게적은것으로나타났다. 이와관련하여헤지의표준화된평균차 (Hedges g) 를보여주는도표는 Figure 2와같다. 메타분석본연구는 Comprehensive Meta-Analysis (version 2.0) 를사용하여효과크기를산출하였다. 각각의연구에서사용된 CCC의하위유형에따른평균, 표준편차와집단의표본크기등을입력하여종합적인효과크기및각각의효과크기 (Hedges s g) 를산출하였으며, 유의수준.05를기준으로효과크기의유의성을검증하였다. Funnel plot of standard error by Hedges's g 0 Standard error Hedges s g Figure 2. Funnel plot of standard error by Hedges g

7 Seungha Song, et al. Meta-analysis of Children s Communication Checklist 연구결과 질적분석 연구대상 본연구의메타분석을위해선정된학술논문은학령전기, 학령 기, 청소년기, 청년기에걸친광범위한연령대의참여자를대상으 로하였으며, 연구에포함된대상자의연령범위는 4 세에서 25 세였 다. 연구대상자의수는 ASD ( 아스퍼거및고기능자폐포함 ) 집단이 총 307 명, ADHD 집단이총 190 명, WS 집단이총 40 명으로장애집 단의총수는 537 명이었으며, 통제집단인비장애집단의총수는 562 명이었다. 분석에포함된연구에서비교집단의하위유형으로 는 ASD ( 아스퍼거및고기능자폐포함 ) 와통제집단을비교한결과 (N=10) 가가장많았고, 그다음으로 ADHD 와통제집단을비교한 결과 (N=7), WS 와통제집단을비교한결과 (N=2) 순이었다. 평가도구 본연구는의사소통장애집단과비장애집단의화용언어능력 평가에대한메타분석연구로, 분석대상논문에서사용된평가도 구는 CCC (Bishop, 1998) 또는 CCC-2 (Bishop, 2003) 이다. 전체논 문 14 편중 CCC 의결과를활용한논문은 3 편, 개정된 CCC-2 의결 과를사용한논문은 11 편이었다. CCC 는양육자또는교사가아동의의사소통행동에관한문항 에대해해당여부를기록하는간접평가형식의도구이다. CCC 는 Table 2. Children s Communication Checklist 2nd edition (CCC-2) subscales CCC CCC-2 Structural Pragmatics Autism/social A: Speech B: Syntax D: Coherence A: Speech B: Syntax C: Semantics D: Coherence C: Inappropriate initiation E: Stereotyped conversation F: Use of context G: Rapport E: Inappropriate initiation F: Stereotyped G: Use of context H: Nonverbal communication H: Social relationships I: Interests I: Social relations J: Interests 화용능력의특성상표준화된평가가어렵고, 발달수준에따라비전형성에대한판단이달라진다는것을고려하여, 화용특성을빠르고손쉽게평가하기위해개발되었다. 2003년 CCC-2로개정되면서, 10개의하위항목에각 7개씩, 총 70문항으로구성되었고, 전체결과를의사소통총점 (general communication composite, GCC), 그리고사회적상호작용일탈점수 (social interaction deviance composite, SIDC) 환산이가능하다. GCC는 A부터 H에이르는하위항목점수의합산이고, SIDC는 A, B, C, D의합에서 E, F, I, J의합을뺀값으로, GCC점수가 55점미만인경우에한하여환산한다. 여기에 E, F, G, H의합산으로이루어진화용점수 (pragmatic composite, PRAG) 에따른표준화된점수가제공되는데, CCC에서화용점수를명확히제시한것과는달리 CCC-2에서는이를제외시켰다. 그이유는검사자간신뢰도와타당도가낮아, 그효과가비장애집단과의변별에만국한되기때문이다 (Bishop, 2003). Table 2에나타난바와같이, CCC의하위항목은초기 9개이던것이, CCC-2에서언어구조적인측면의 의미영역 이추가되면서 10 개로늘어났다. 이는 CCC-2를단순히화용능력평가도구로활용하는것이아니라, 의사소통장애전반에걸친선별도구로활용하기위해서이다 (Norbury et al., 2004). CCC-2 에서는하위항목의명칭과세부문항이수정되었지만, 전체를다시언어구조, 화용, 자폐- 사회성의세가지큰영역으로분류하였다. 단, 기존에화용오류의대표적인특성중하나로언급되는응집력 (coherence) 의경우, 화용언어장애집단과 SLI 집단을변별해내는데실패하면서언어구조적인영역에포함하였다. 이에대해서는논란의여지는있으나, Norbury 등 (2004) 은이야기능력은화용언어능력에비해언어자체의핵심적인능력과깊은관계가있다는데에서근거해서언어구조영역에포함시켰다고설명하였다. 본연구에서는 CCC의하위항목을모두변수로포함시키지않고, Table 2에서제시된세가지영역을기준으로점수를환산하여분석하였다. GCC는의사소통전반에대한환산점수이므로, 본연구의목적에부합하지않으며, SIDC는 GCC가낮은대상에한하여환산가능하며, 공식에따른환산점수이기때문에활용하지않았다. Table 3. Effect size of ASD, ADHD, and WS versus control participants CCC score Effect size and 95% CI Homogeneity tests Hedges g Lower limit Upper limit p-value Q df (Q) p-value I 2 All clinical population <.05 6, < ASD < , < ADHD < , < WS > < ASD= autism spectrum disorder; ADHD= attention-deficit/hyperactivity disorder; WS= Williams syndrome; CCC= Children's Communication Checklist

8 아동의사소통체크리스트 (CCC) 를활용한화용언어장애아동의의사소통능력평가에대한메타분석 송승하외 Table 4. Effect size of sub-domain results of CCC: each clinical populations vs. controls CCC sub-domain ASD vs. TD Structural Pragmatics Autism/social ADHD vs. TD Structural Pragmatics Autism/social Effect size and 95% CI Homogeneity tests Hedges g Lower limit Upper limit p-value Q df (Q) p-value I ,402 <.05 <.05 <.01 <.01 <.05 > , <.001 <.001 <.001 <.001 <.001 < CCC= Children s Communication Checklist; ASD= autism spectrum disorder; ADHD= attention-deficit/hyperactivity disorder; TD= typically developing. 의사소통장애집단 (ASD, ADHD, WS) 과통제집단의 CCC 평가결과비교 CCC를활용하여 ASD, ADHD, 그리고 WS로나눈장애집단과통제집단의 CCC 종합점수차이에대한메타분석결과는 Table 3 과같다. 전체의사소통장애집단의효과크기는 g = -.295, p<.05, 95% 신뢰구간 [-.533, -.058] 에해당하여, 비장애집단과유의하게차이를보였다. 의사소통장애집단의하위그룹중, ASD의효과크기는 g = -.954, p<.0001, 95% 신뢰구간 [-1.320, -.587], ADHD의효과크기는 g =.475, p<.0001, 95% 신뢰구간 [.209,.741], WS의효과크기는 g = , p =.744, 95% 신뢰구간 [-1.205,.860] 에해당하였다. ASD와 ADHD, 그리고 WS를하나의집단으로묶어정상발달통제집단과 CCC 결과의차이를살펴봤을때, 이는유의하게나타났다. 그러나, 하위그룹으로나누었을때, ASD와 ADHD는 CCC 결과가통제집단에비해유의하게낮았지만, WS와통제집단간에는유의한차이가없었다. 이에대한결과를 Table 3에제시하였다. 통제집단과유의한차이를보이는장애집단 (ASD, ADHD) 의 CCC 세부프로파일지금까지집단간비교결과, 전체의사소통장애집단은비장애집단과의미있는차이를보였고, ASD, ADHD 집단또한비장애집단과유의한차이를보였지만, WS 집단은유의한차이를보이지않았다. 이에따라통제집단과유의한차이를보이는 ASD, ADHD 집단의 CCC 세부프로파일을살펴보았다. ASD와비장애집단, 그리고 ADHD와비장애집단의 Forest Plot은각각 Appendixes 1, 2 와같다. 집단간차이를불러일으키는장애집단의 CCC 하위영역을알아보기위해본연구에서는언어구조, 화용, 자폐-사회성영역에따른결과를분석하였고, 그결과는 Table 4와같다. ASD 집단은언어구조영역에서효과크기 g = -.564, p =.036, 95% 신뢰구간 [-1.090, -.037], 화용영역에서효과크기 g = , p=.036, 95% 신뢰구간 [-1.499, -.191], 그리고자폐-사회성영역에서효과크기 g = , p =.005, 95% 신뢰구간 [-2.072, -.378] 로, 모든하위영역에서비장애집단과유의한차이를보였다. ADHD 집단은언어구조영역에서효과크기 g =.583, p=.001, 95% 신뢰구간 [.251,.915], 화용영역에서효과크기 g =.619, p=.013, 95% 신뢰구간 [-.130, 1.108] 로의미있는차이를보였으나, 자폐-사회성영역에서는효과크기 g =.616, p=.125, 95% 신뢰구간 [-.170, 1.402] 로유의한차이를보이지않았다. 논의및결론본연구는화용결함이나타나는 ASD, ADHD, 그리고 WS 집단이아동의사소통체크리스트 (CCC, CCC-2) 를통해비장애집단과구별되는의사소통및화용결함을입증할수있는지, 화용을포함한언어구조및자폐-사회성의하위영역에서각집단간세부프로파일상의차이가나타나는지확인하고자메타분석을실시하였다. 그결과, ASD와 ADHD 집단은또래비장애집단과유의한차이를보였으나, WS 집단은유의한차이를보이지않았다. 그룹간유의한차이를불러일으키는하위항목을알아보기위해, CCC 를언어구조, 화용, 자폐-사회성영역으로나눈분류기준에따라집단간차이를분석하였다. 비장애집단과의비교결과, ASD 집단은세영역모두에서의미있는차이를보였지만, ADHD 집단은언어구조와화용에서만유의한차이를보였다. 선행연구결과와마찬가지로, 본메타분석결과에서도비장애집단과장애집단을변별하는데유의하였다 (Norbury et al., 2004; Volden & Phillips, 2010). 장애집단을 ASD, ADHD, WS와같이세부적으로나누어 CCC 결과를살펴보았을때, ASD와 ADHD 집단은비장애집단과유의한차이를보였으나, WS 집단은비장애집단과유의한차이를보이지않았다. 이는 ASD 집단은전반적인의사소통및화용언어기술에서어려움을보였으며, ADHD 집단의경우에도역시화용적인 443

9 Seungha Song, et al. Meta-analysis of Children s Communication Checklist 어려움을보인다고보고한선행연구와일치하는결과라할수있다 (Bishop & Baird, 2001). WS 집단의경우다른화용결함을보이는장애집단에비해전반적인화용언어기술에서유의하게나은수행을보이며, 높은공감능력을지녀화용에서약점을보이지않는다고제안한결과들과일치한다 (Jones et al., 2000; Philofsky et al., 2007; Rice, Warren, & Betz, 2005). 그러나 WS 집단이사회적관계에대한강한열망은지니나과도한친밀함표현으로오히려또래관계를형성및유지하는데에는어려움을보여화용결함이나타날수있음을언급한연구와는상반되는결과이다 (Hoffmann, Martens, Fox, Rabidoux, & Andridge, 2013). CCC는직접또는관찰평가가아닌주양육자또는아동과정기적으로접촉하는성인에의한체크리스트형식의간접평가로, 임상적으로유의한의사소통및화용상의어려움을선별하는데에목적이있는만큼, WS 집단이보이는고유한어려움인 과도한사회적행동 (hyper-social behavior) 을민감하게탐지하기에는어려움이있었을것으로분석된다 (Bellugi, Lichtenberger, Jones, Lai, & St. George, 2000). 또한 WS 집단은타인이느끼고생각하는특정방식을고려하는것에어려움을느끼는인지적통찰력의부족을보이는것으로알려져있지만, 타인의정서에공감하는정서적통찰력은존재한다고보고되고있기에, 이러한정서적통찰력이존재함으로인해이들의화용결함이부모의체크리스트를기반으로한 CCC를통해서는드러나지않았을것으로추론된다 (Tager-Flusberg & Sullivan, 2000). 즉, WS 집단이화용어려움을지닌다고알려진것은언어의구조적어려움에기인하기보다는이집단의특징적인인지능력에서의전반적인결함때문일수있다 (Stojanovic, 2006). 한편, 비장애집단과유의한차이를보이는 ASD, ADHD 집단의경우각각의장애집단내에서나타나는어려움들이상당히중첩될수있지만고유의어려움은다를수있기때문에세부적인프로파일을살펴보는것은더욱의의가있다. 이에따라본연구는집단간의차이를불러일으키는영역으로, 하위항목을언어구조, 화용, 자폐-사회성으로재분류한것을활용하였다. 그결과, ASD 집단은비장애집단과세영역모두에서차이를보였지만, ADHD 집단은언어구조와화용에서만차이를보였다. 특히화용결함은일생동안지속되는반면, 다른언어구조적어려움들은아동이성숙해감에따라습득될수있다고언급한선행연구에근거하여 (Rapin & Dunn, 2003), ASD 집단의경우화용및자폐-사회성영역에서의주된어려움만을지닐것으로예상하였으나, 언어구조영역에서도결함을보인것은주목할만한점이다. ASD 집단의아동은화용및사회적관계와같은영역에서더욱심각한문제를보이지만, 구문과같은구조언어적문제역시존재하며, 이것은아동의연령이어릴수 록더욱두드러졌다 (Geurts & Embrechts, 2008). 이는 ASD 집단이화용및자폐-사회성영역의결함뿐아니라언어형식에서의결함도보인다고보고한 Geurts 등 (2004) 의연구와일치하는결과이다. 자폐-사회성영역은자폐스펙트럼장애의진단적특성인사회적관계와제한된관심사가반영된것으로볼수있다 (Norbury et al., 2004). 그러므로 ADHD 집단에서는나타나지않았던이영역에서의어려움이 ASD 집단에서는유의하게나타난것으로분석된다. ADHD 집단의언어구조및화용상의어려움은이들이지닌주의력결핍및충동성문제와더불어나타난다. 즉기억시스템에서목표어휘에접근하고인출및활성화하는의미론적결함, 이야기및대화능력에서차례기다리기, 주제유지하기에서의어려움, 이야기특성에서의비조직화및취약한응집력, 그리고전반적인화용상의결함들이복합적으로존재하는것이다 (Engelhardt et al., 2011; Safwat et al., 2013). 이에따라 ADHD 집단은언어사용또는운동반응조절에서의낮은수준의통제메커니즘을보이며, 화용상의결함과더불어말, 구문, 의미, 응집력등의언어구조상의결함역시존재한다는것이 CCC를통해서도나타난것으로보인다. 이러한영역의특성을고려할때, CCC 결과는 ASD나 ADHD를비장애집단과변별하는데에서더나아가, 이두집단의진단적특성을반영한다고할수있다 (Bishop, 2003; Norbury et al., 2004). 그러나 Bishop (2003) 이 CCC-2 를개정하며밝혔듯이, 화용영역은비장애집단과의변별수준에서의미있다는점이반영된것이므로, 화용영역에서공통적으로어려움을보이는 ASD와 ADHD 두집단을직접비교하는데에는주의가필요하다. PRAG 점수가의사소통장애간에나타나는화용프로파일의상이함을반영하지못한다는본연구의결과가이를뒷받침하고있다. 의사소통장애는하위분류에따라말 언어프로파일이다르고, 이와같은차이는타인과의상호작용, 더나아가서는관계형성에영향을미친다. ASD나 ADHD, 그리고 WS 집단도진단적특성에따라말 언어프로파일이다르므로각장애특성에따른화용상의어려움역시다양하게나타날수있다 (Philofsky et al., 2007). 예를들어, ASD는또래관계형성및유지욕구가결여되어있는것에기인하여전반적인화용및사회성영역에서결함을나타내는반면 (Geurts et al., 2004; Verté et al., 2006), ADHD나 WS는또래관계에대한욕구는상당하지만, 타인이느끼고생각하는특정방식에대해고려하는인지적통찰력이부족하기때문에, 전반적인화용능력및사회적관계형성이원만하지않을수있다 (Tager-Flusberg & Sullivan, 2000). 이들의각기다른화용및사회적능력에서의어려움에대해적절하게지원하기위해, 화용의세부적인하위영역중구체적으로어떤것이이들의어려움에영향을미치는지에대한 444

10 아동의사소통체크리스트 (CCC) 를활용한화용언어장애아동의의사소통능력평가에대한메타분석 송승하외 원인분석이필요하다. 이런의미에서 CCC는비장애집단으로부터의사소통전반또는화용상의문제를선별하는데있어매우훌륭한도구라할수있다. 하지만의사소통장애집단에따른각기다른프로파일을설명하기위해단독으로사용하기에는충분하지못한것으로보인다 (Norbury et al., 2004). 그러므로다양한장애군의특성에따라화용문제를지원하기위해서는직접평가와병행하였을때, 민감도가잘반영된평가가이루어질수있을것으로기대된다. 결론적으로, 본연구결과에서 CCC를통해의사소통및화용상의어려움을선별하고더욱세부적인검사가필요한아동들을확인하는데에도움이될수있으나, 각장애군에따른뚜렷한차이를단정짓기에는무리가있음을확인하였다. 따라서, 본연구의한계및후속연구를위한제언으로는본연구의포함및제외기준을충족하는분석대상의논문편수가 14편으로다소적은편수임을고려할때추후더많은문헌이포함되거나, 관련연구들이더욱활발히진행되어야할것이다. 또한, 본연구에사용된문헌에서연구대상의광범위한연령대로인해각하위항목에따른점수에서연령에따른차이에의한영향력이통제되지못했을가능성이제기되므로후속연구에서는보다한정된연령대에서의결과들을살펴보아야할것으로보인다. REFERENCES Adams, C. (2002). Practitioner review: the assessment of pragmatics. Journal of Child Psychology and Psychiatry, 43, Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychological Bulletin, 121, Baron-Cohen, S. (1988). Social and pragmatic deficits in autism: cognitive or affective? Journal of Autism and Developmental Disorders, 18, Bates, E. (1976). Language in context. New York: Academic Press. Bellugi, U., Lichtenberger, L., Jones, W., Lai, Z., & St. George, M. (2000). The neurocognitive profile of Williams syndrome: a complex pattern of strengths and weaknesses. Journal of Cognitive Neuroscience, 12(Supplement 1), Bishop, D. V. (1998). Development of the Children s Communication Checklist (CCC): a method for assessing qualitative aspects of communicative impairment in children. Journal of Child Psychology and Psychiatry, 39, Bishop, D. V. (2003). The Children s Communication Checklist: CCC-2. London: Harcourt Assessment. Bishop, D. V., & Adams, C. (1989). Conversational characteristics of children with semantic pragmatic disorder. II: What features lead to a judgement of inappropriacy? International Journal of Language & Communication Disorders, 24, Bishop, D. V., & Baird, G. (2001). Parent and teacher report of pragmatic aspects of communication: use of the Children s Communication Checklist in a clinical setting. Developmental Medicine & Child Neurology, 43, Botting, N., & Conti Ramsden, G. (2003). Autism, primary pragmatic difficulties, and specific impairment: can we distinguish them using psycholinguistic markers? Developmental Medicine & Child Neurology, 45, Choi, J., & Lee, Y. (2013). Conversational turn-taking and topic manipulation skills of children with high-functioning autism spectrum disorders. Communication Science & Disorders, 18, Choi, J., & Lee, Y. (2015). Contingency and informativeness of topic maintenance in children with high-functioning autism spectrum disorders. Communication Science & Disorders, 20, Crick, N. R., & Dodge, K. A. (1994). A review and reformulation of social information-processing mechanisms in children s social adjustment. Psychological Bulletin, 115, Curcio, F., & Paccia, J. (1987). Conversations with autistic children: contingent relationships between features of adult input and children s response adequacy. Journal of Autism and Developmental Disorders, 17, Engelhardt, P. E., Corley, M., Nigg, J. T., & Ferreira, F. (2010). The role of inhibition in the production of disfluencies. Memory & Cognition, 38, Engelhardt, P. E., Ferreira, F., & Nigg, J. T. (2011). Language production strategies and disfluencies in multi-clause network descriptions: a study of adult attention-deficit/hyperactivity disorder. Neuropsychology, 25, Geurts, H. M., Verté, S., Oosterlaan, J., Roeyers, H., Hartman, C. A., Mulder, E. J.,... & Sergeant, J. A. (2004). Can the Children s Communication Checklist differentiate between children with autism, children with ADHD, and normal controls? Journal of Child Psychology and Psychiatry, 45, Geurts, H. M., & Embrechts, M. (2008). Language profiles in ASD, SLI, and ADHD. Journal of Autism and Developmental Disorders, 38, Geurts, H. M., Verté, S., Oosterlaan, J., Roeyers, H., & Sergeant, J. A. (2004). How specific are executive functioning deficits in attention deficit hyperactivity disorder and autism? Journal of Child Psychology and Psychiatry, 445

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13 Seungha Song, et al. Meta-analysis of Children s Communication Checklist Appendix 1. Forest plot of meta-analysis: ASD vs. TD Study name Subgroup within study Outcome Statistics for each study Hedges's g and 95% CI Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-value Volden, & Phillips(2010) ASD/TD CCC-2(GCC) Volden, & Phillips(2010) ASD/TD CCC-2(SIDC) Helland et al.(2010) AS/TD CCC-2(A: SPEECH) Helland et al.(2010) AS/TD CCC-2(B: SYNTAX) Helland et al.(2010) AS/TD CCC-2(C: SEMANTICS) Helland et al.(2010) AS/TD CCC-2(D: COHERENCE) Helland et al.(2010) AS/TD CCC-2(E: INAPPRORIATE INITIATION) Helland et al.(2010) AS/TD CCC-2(F: STEREOTYPED LANGUAGE) Helland et al.(2010) AS/TD CCC-2(G: USE OF CONTEXT) Helland et al.(2010) AS/TD CCC-2(H: NONVERBAL COM.) Helland et al.(2010) AS/TD CCC-2(I: SOCIAL RELATIONS) Helland et al.(2010) AS/TD CCC-2(J: INTERESTS) Geurts, & Embrechts(2008) ASD/TD CCC-2(A: SPEECH) Geurts, & Embrechts(2008) ASD/TD CCC-2(B: SYNTAX) Geurts, & Embrechts(2008) ASD/TD CCC-2(C: SEMANTICS) Geurts, & Embrechts(2008) ASD/TD CCC-2(D: COHERENCE) Geurts, & Embrechts(2008) ASD/TD CCC-2(E: INAPPRORIATE INITIATION) Geurts, & Embrechts(2008) ASD/TD CCC-2(F: STEREOTYPED LANGUAGE) Geurts, & Embrechts(2008) ASD/TD CCC-2(G: USE OF CONTEXT) Geurts, & Embrechts(2008) ASD/TD CCC-2(GCC) Geurts, & Embrechts(2008) ASD/TD CCC-2(GPS) Geurts, & Embrechts(2008) ASD/TD CCC-2(H: NONVERBAL COM.) Geurts, & Embrechts(2008) ASD/TD CCC-2(I: SOCIAL RELATIONS) Geurts, & Embrechts(2008) ASD/TD CCC-2(J: INTERESTS) Geurts, & Embrechts(2008) ASD/TD CCC-2(SIDC) Sadiq, Slator, Skuse, Law, Gillberg, & Minnis(2022) ASD/TD CCC(A: SPEECH) Sadiq, Slator, Skuse, Law, Gillberg, & Minnis(2023) ASD/TD CCC(B: SYNTAX) Sadiq, Slator, Skuse, Law, Gillberg, & Minnis(2024) ASD/TD CCC(C: INAPPRORIATE INITIATION) Sadiq, Slator, Skuse, Law, Gillberg, & Minnis(2025) ASD/TD CCC(D: Coherence) Sadiq, Slator, Skuse, Law, Gillberg, & Minnis(2026) ASD/TD CCC(E: Stereoptyped Conversation) Sadiq, Slator, Skuse, Law, Gillberg, & Minnis(2027) ASD/TD CCC(F: Use of conversational context) Sadiq, Slator, Skuse, Law, Gillberg, & Minnis(2028) ASD/TD CCC(G: Conversational rapport) Sadiq, Slator, Skuse, Law, Gillberg, & Minnis(2029) ASD/TD CCC(H: Social relationships) Sadiq, Slator, Skuse, Law, Gillberg, & Minnis(2030) ASD/TD CCC(I: Interests) Sadiq, Slator, Skuse, Law, Gillberg, & Minnis(2031) ASD/TD CCC(C-G: Pragmatics) Norbury, Nash, Baird, Bishop(2004) ASP/TD CCC-2(A: SPEECH) Norbury, Nash, Baird, Bishop(2004) ASP/TD CCC-2(B: SYNTAX) Norbury, Nash, Baird, Bishop(2004) ASP/TD CCC-2(C: SEMANTICS) Norbury, Nash, Baird, Bishop(2004) ASP/TD CCC-2(D: COHERENCE) Norbury, Nash, Baird, Bishop(2004) ASP/TD CCC-2(E: INAPPRORIATE INITIATION) Norbury, Nash, Baird, Bishop(2004) ASP/TD CCC-2(F: STEREOTYPED LANGUAGE) Norbury, Nash, Baird, Bishop(2004) ASP/TD CCC-2(G: USE OF CONTEXT) Norbury, Nash, Baird, Bishop(2004) ASP/TD CCC-2(H: NONVERBAL COM.) Norbury, Nash, Baird, Bishop(2004) ASP/TD CCC-2(I: SOCIAL RELATIONS) Norbury, Nash, Baird, Bishop(2004) ASP/TD CCC-2(J: INTERESTS) Norbury, Nash, Baird, Bishop(2004) HFA/TD CCC-2(A: SPEECH) Norbury, Nash, Baird, Bishop(2004) HFA/TD CCC-2(B: SYNTAX) Norbury, Nash, Baird, Bishop(2004) HFA/TD CCC-2(C: SEMANTICS) Norbury, Nash, Baird, Bishop(2004) HFA/TD CCC-2(D: COHERENCE) Norbury, Nash, Baird, Bishop(2004) HFA/TD CCC-2(E: INAPPRORIATE INITIATION) Norbury, Nash, Baird, Bishop(2004) HFA/TD CCC-2(F: STEREOTYPED LANGUAGE) Norbury, Nash, Baird, Bishop(2004) HFA/TD CCC-2(G: USE OF CONTEXT) Norbury, Nash, Baird, Bishop(2004) HFA/TD CCC-2(H: NONVERBAL COM.) Norbury, Nash, Baird, Bishop(2004) HFA/TD CCC-2(I: SOCIAL RELATIONS) Norbury, Nash, Baird, Bishop(2004) HFA/TD CCC-2(J: INTERESTS) Verte et al.(2006) AS/TD A: Speech Verte et al.(2006) AS/TD B: Syntax Verte et al.(2006) AS/TD C: Inappropriate Initiation Verte et al.(2006) AS/TD D: Coherence Verte et al.(2006) AS/TD E: Stereotyped Conversation Verte et al.(2006) AS/TD F: Use of converational context Verte et al.(2006) AS/TD G: Converational Rapport Verte et al.(2006) AS/TD H: Social relations Verte et al.(2006) AS/TD I: Interests Verte et al.(2006) AS/TD Pragmatic Composite(C-G) Verte et al.(2006) HFA/TD A: Speech Verte et al.(2006) HFA/TD B: Syntax Verte et al.(2006) HFA/TD C: Inappropriate Initiation Verte et al.(2006) HFA/TD D: Coherence Verte et al.(2006) HFA/TD E: Stereotyped Conversation Verte et al.(2006) HFA/TD F: Use of converational context Verte et al.(2006) HFA/TD G: Converational Rapport Verte et al.(2006) HFA/TD H: Social relations Verte et al.(2006) HFA/TD I: Interests Verte et al.(2006) HFA/TD Pragmatic Composite(C-G) Guerts et al.(2004) HFA/TD A: Speech Guerts et al.(2004) HFA/TD B: Syntax Guerts et al.(2004) HFA/TD C: Inappropriate Initiation Guerts et al.(2004) HFA/TD D: Coherence Guerts et al.(2004) HFA/TD E: Stereotyped Conversation Guerts et al.(2004) HFA/TD F: Use of converational context Guerts et al.(2004) HFA/TD G: Converational Rapport Guerts et al.(2004) HFA/TD H: Social relations Guerts et al.(2004) HFA/TD I: Interests Guerts et al.(2004) HFA/TD Pragmatic Composite(C-G) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(A: SPEECH) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(B: SYNTAX) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(C: SEMANTICS) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(D: COHERENCE) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(E: INAPPRORIATE INITIATION) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(F: STEREOTYPED LANGUAGE) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(G: USE OF CONTEXT) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(GCC) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(H: NONVERBAL COM.) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(I: SOCIAL RELATIONS) Philofsky, Fidler, & Hepburn(2007) ASD/TD CCC-2(J: INTERESTS) Philofsky, Fidler, & Hepburn(2007) ASD/TD PRAG ASD TD 448