Pragmatics performance, the relation to symptom severity, and early clinical predictors of pragmatics in 5~6-year-old children with autism spectrum disorder

Pragmatics performance, the relation to symptom severity, and early clinical predictors of pragmatics in 5~6-year-old children with autism spectrum disorder | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pragmatics performance, the relation to symptom severity, and early clinical predictors of pragmatics in 5~6-year-old children with autism spectrum disorder Lu Qian, Ning Ding, Hui Fang, Ting Xiao, Bei Sun, HuiYun Gao, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4703774/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Jan, 2025 Read the published version in BMC Psychiatry → Version 1 posted 10 You are reading this latest preprint version Abstract Background Pragmatic language refers to the use of spoken language to effectively convey messages across diverse social communication contexts. However, minimal longitudinal research has focused on defining early predictors of pragmatic development in children with autism spectrum disorder (ASD). Methods In the current study, 71 ASD and 38 age- and gender- matched 24- to 30-month-old typically developing (TD) children were enrolled. Social-communication, language, and parent-child interaction measures were collected for the ASD group at baseline. Three years later, all subjects were assessed for pragmatic ability via the Chinese version of Language Use Inventory (LUI-Mandarin). First, the differences of pragmatic performance between the ASD group and the TD group at follow-up were analyzed. Second, pragmatic performance was correlated with autism symptomatology at follow-up, as well as the structural language difficulties and joint engagement (JE) levels at baseline for the ASD group. Furthermore, diverse multiple regression algorithms were performed to explore the effect of the early potential predictors of pragmatic development for the ASD group. Results First, our results revealed that performance was significantly lower in the ASD group than in the TD group with respect to LUI-Mandarin Total scores and subscale scores ( t = -3.358 ~ -6.870, p < 0.05). Second, correlation analysis showed that more severe symptoms of ASD at follow-up were associated with lower LUI-Mandarin Total scores ( r = -0.489 ~ -0.853, p < 0.05), and better language performance of Gesell ( r = 0.555, p < 0.05). In addition, increased proportions of supported JE(SJE) state ( r = 0.591, p < 0.05) were associated with higher LUI-Mandarin Total scores, while increased proportions of unengaged (UE) state were associated with lower LUI-Mandarin Total scores ( r = -0.295, p < 0.05) for the ASD group. Third, diverse multiple regression algorithms consistently indicated that the proportions of SJE during parent-child interactions was a significant contributor to pragmatic development for the ASD group in the prediction models. Conclusion In summary, our findings suggest that pragmatic language difficulties are present in children with ASD as early as preschool age. Additionally, given the close correlation between the LUI-Mandarin and symptom severity on ADOS/ADI-R, the LUI-Mandarin might be a good way to triage children who need to wait a long time for a more extensive evaluation. Furthermore, more time occupied in SJE could be an important predictor for better pragmatic language outcomes for children with ASD. autism spectrum disorder pragmatics predictors supported joint engagement Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Autism spectrum disorder (ASD) is an early onset neurodevelopmental disorder characterized by deficits in social communication, social interaction and restricted/repetitive behaviors or interests, which seriously affect the patient's social, academic, family, and other aspects [ 1 ]. To date, the etiology of ASD is unclear. It is believed that the pathogenesis of ASD is a result of an interaction of genetics and environment [ 2 – 3 ]. A recent Chinese multi-center study estimated that the prevalence of ASD is as high as 0.7%, with a male to female ratio of about 3:1 [ 4 ]. At present, the diagnosis of ASD is mainly based on behavioral manifestations. Although there is great heterogeneity between and within individuals, the core characteristics of ASD can still be reliably identified [ 5 ]. Although in the United States, the median age of ASD diagnosis remains stubbornly at 4 to 5 years [ 6 ], early warning signs can be observed in infancy [ 7 ]. Longitudinal studies of individuals with ASD have identified high-risk behaviors such as poor eye contact, lack of visual tracking, failure to respond to names, poor imitation skills, lack of social interest, and limited language ability [ 8 – 9 ]. Studying the early behavioral signs of individuals with ASD is the first step toward early identification, referral, diagnosis, and intervention. A growing number of studies support the efficacy of early behaviorally based interventions in ASD for the improvement of social communication and behavioral functioning to varying degrees [ 10 – 12 ]. Pragmatic language and ASD‑related characteristics Pragmatic language refers to the ability to use spoken language to effectively convey information in different social contexts [ 13 ], which is frequently demonstrated to be a key component of the difficulties exhibited by individuals with ASD [ 14 – 16 ] .The new DSM-5 diagnosis of Social (Pragmatic) Communication Disorder (SPCD) also aims to identify individuals with pragmatic disorders. Because pragmatic language depends on more sophisticated developments of speech and language among other factors, a formal diagnosis of SPCD is rarely made in children younger than 4 years of age, although difficulties and delays in social (pragmatic) communication can be assessed and identified prior to this age [ 17 ]. Indeed, early signs of ASD may involve early pragmatic communication such as non-typical use and understanding of gestures, and differences in attention to social peers and common topics. In addition, about 30% of the individuals with ASD can only obtain minimal language communication with age [ 18 ]. With respect to those who have developed spoken language, pragmatic difficulties often persist, characterized by difficulties in the attempt to communicate and narrow communicative behaviors [ 19 ]. Moreover, pragmatic language difficulties may persist into adolescence and adulthood in ASD, as evidenced by poor topic management during conversation, frequent appearance of off-topic information, unusual rhythm in speech, reduced social reciprocity and response to social cues from peers [ 20 – 21 ]. Studies have shown that the effects of pragmatic impairments are far-reaching, and found to be associated with a greater incidence of behavioral problems, especially destructive and externalizing behaviors [ 22 ]. Among children, the long-term negative effects of pragmatic impairments include poor peer relations [ 23 ], being excluded and rejected by peers in school [ 24 – 25 ], and having difficulties forming successful social relations in adulthood [ 26 – 27 ]. Miranda et al [ 28 ] examined the relationships between the social communication questionnaire (SCQ) domains (including reciprocal social interaction, communication, and restricted and repetitive behaviors (RRBs)) and pragmatic language controlling for sex and vocabulary in children with ASD, and showed that the SCQ reciprocal social interaction domain correlated significantly with the pragmatic index, whereas there was no significant relationship with RRBs. However, previous studies have examined the association between the degree and type of RRBs and levels of functioning in ASD, showing that children with higher levels of RRBs were more likely to present with less developed receptive and expressive language abilities, and lower adaptive communication and socialization skills [ 29 ]. Joint attention and pragmatic language Evidence of brain development and key stages of neural plasticity in infancy lends strong support to the importance of early intervention [ 30 ]. Studies have shown that early intervention is efficacious in modifying cognitive and social-communicative outcomes and potentially improving developmental trajectories in toddlers with ASD [ 8 – 9 , 11 ]. Longitudinal studies of ASD can help understand the association between early developmental trajectories and outcomes, and provide benchmarks for early interventions. Joint attention (JA) is a tertiary interactive process composed of two social partners and an object, and is an important component in the development of early social communication in typically-developing infants [ 31 ]. JA is often defined by measures that assess a discrete set of children’s skills using structured tasks (i.e., whether an infant can use pointing and eye gaze to share attention to an object). As early as 6 months of age, infants’ gaze can follow the caregiver to a new location [ 32 ], and, by 12 months of age, they can establish JA in various ways, such as looking at the caregiver and the object alternately, reaching for the object, or lifting the object to show to others [ 33 ]. These behaviors can help them build shared concerns for an object or event with social partners [ 33 ]. Difficulties with JA occur in ASD from infancy, and they are often one of the earliest signs accompanying a diagnosis of ASD [ 34 – 35 ]. There are two types of JA: response to joint attention (RJA) and initiation of joint attention (IJA). RJA is considered a more involuntary process of attention following, which can be improved to a certain extent with the development in individuals with ASD, whereas IJA is considered a more active process to share an experience, which shows little change with age in individuals with ASD [ 36 – 37 ]. RJA and IJA are both critical for the development of language in early childhood, especially for ASD [ 38 ] When children engage in JA, they engage in a social situation that helps to associate words with meaning and develop interactive abilities [ 39 ]. Several prospective studies have investigated the correlation between early JA levels and later pragmatic abilities in children at risk for ASD. For example, in 2015, Gillespie-Lynch et al. (2015) [ 40 ] evaluated JA levels in high-risk children with ASD at 12 and 18 months and explored the relationship between early JA levels and children’s pragmatic and structural language abilities 6 years later. Their results showed that response to joint attention (RJA) at 18 months of age could predict structural language but not pragmatic language in high-risk children with ASD. Greenslade et al. (2019) [ 41 ] collected social and language data in children at risk for ASD from 14 to 36 months old, and evaluated their pragmatic levels using the Pragmatic Rating Scale-School-age (PRS-SA) adapted from the PRS [ 42 ] from 8 to 12 years old. They found that the JA levels at 14 months of age could predict later pragmatic abilities in children at risk for ASD at school age. Joint engagement and pragmatic language Previous studies have mainly focused on the importance of early JA for pragmatic language development, especially for siblings of children with ASD[ 40 – 41 , 43 ]. However, neurotypical infants rarely look at the caregivers’ faces before attending to an object during social interactions in reality [ 44 – 45 ], and children with ASD may engage with others in ways that are not captured in standard measures of JA [ 46 – 47 ]. In contrast, rather than assessing discrete skills, joint engagement (JE) is evaluated with respect to mutual and extended caregiver-child interactions in which a child and social partner sustain active involvement in the context of toy play [ 48 – 49 ]. JE may be more practical for interventions than JA because JE focuses on the interaction between caregiver and child, whereas JA is more relevant to objects and events. Interventions can be designed around promoting JE between caregiver and child [ 50 ]. The importance of JE was confirmed by a recent study showing that JE was a major predictor of expressive language even when JA was considered[ 49 ]. Adamson distinguished between three types of JE: (1) Coordinated JE (CJE), the most developmentally advanced periods, which requires the infant to make eye contact with the social partner; (2) Supported JE (SJE), a state in which the infant is actively involved with the same object as the social partner without making eye contact; and, (3) Object Engagement (OE), in which the infant is exclusively engaged with objects and not with the social partner[ 51 ]. For typically developing (TD) children, SJE accounted for a large proportion of play during the first two years of life, and by the age of 12 months, CJE began to appear, with an increase at the age of 24 months [ 48 ]. Children with ASD aged 2 to 3 years had a lower proportion of CJE and spent more time involved in OE than age and speech level matched TD children [ 52 ]. However, children with ASD had a higher proportion of SJE in parent-child play interactions, compared to their TD peers [ 49 ]. Studies have shown that the language outcome of children with ASD is related to the frequency of SJE, but not closely related to CJE. One possible explanation might be that the frequency of CJE is lower than that of SJE, and it almost does not occur in the communicative interactions between children with ASD and their caregivers [ 49 ]. Structural language and pragmatic language The form (such as phonology, vocabulary, and syntax) and content (semantics) of language represent structural language. Pragmatic language needs to be expressed through structural language and social context, and structural language is a key element of pragmatic language. Pragmatic language is closely related to structural language, supported by studies that have shown that deficits in structural language are common in children with ASD and are related to pragmatic impairment [ 53 – 55 ]. In addition, studies have shown that structural language is a key predictor of non-literal pragmatic forms of language use such as idioms and metaphors [ 56 – 57 ]. Also, a meta-analysis showed that when the ASD group was matched with the TD group in terms of structural language performance, no significant difference was found in performance on pragmatic tasks [ 58 ]. To summarize, these studies suggest the importance of structural language to pragmatic language. Current study In neurotypical development, early JA, broader social-communication behaviors (e.g., shared enjoyment, gesture use), and structural language are the theoretical precursors of advanced social cognition. Social cognitive skills, as well as the ability to combine appropriate vocabulary and nonverbal communication behaviors in efficient well-formed expressive messages, are critical to later effective pragmatic communication [ 59 – 60 ]. Although the effects of the above factors on pragmatic outcomes have been studied separately, they have not been jointly studied as predictors of pragmatic language in the same model in children with ASD. Thus, the relative contribution of early predictors of pragmatic development - JA and especially JE and/or structural language - in ASD is unclear. Therefore, the current study examined pragmatic communication functioning in preschool-age children with ASD and TD controls, as well as the association with autistic symptoms and the early predictors of this functioning in the ASD sample. The following research hypotheses were addressed. First, between-group differences in pragmatic communication functioning at preschool years were examined, comparing the ASD group and TD controls. More specifically, TD controls were hypothesized to demonstrate significantly better preschool-age pragmatic communication functioning than the ASD group. Second, correlations between preschool-age pragmatic communication and autistic symptoms were expected to be significant when conducted with the ASD sample. Finally, in regression models, the combined set of 24-month frequency of joint engagement and structural language abilities were expected to explain a significant amount of the variance in later pragmatic communication in the ASD sample. Methods Participants In total, 71 children with ASD (56 boys and 15 girls) and 38 TD controls (25 boys and 13 girls) ranging in age between 23 and 30 months were enrolled in this study. All participants completed the general condition scale, parenting stress survey and developmental assessment at the time of enrollment. Three years later (around the age of 5 to 5.5 years), totally 44 of the 71 children with ASD received diagnostic assessment, while all participants received pragmatic language assessment. For the patient group, inclusion criteria included: (1) participants were enrolled from a cohort study on ASD from October 2017; (2) the Modified Checklist for Autism in Toddlers (M-CHAT) for the participants was positive; (3) participants were diagnosed according to DSM-5 by two attending child psychiatrists or above, and met the core symptoms of ASD diagnostic criteria, but the age was less than 36 months. Exclusion criteria were as follows: (1) participants with any other diagnosed genetic syndromes or neurological conditions; (2) premature children and those with complications after birth; (3) a history of craniocerebral trauma; (4) chronic medical conditions; (5) visual or hearing impairments; (6) if they were exposed to a language other than Chinese more than 20% of the time since birth. In recruiting the TD group, participants with comparable general demographic data such as age and gender were sought. Exclusion criteria for the TD group were as follows: (1) any genetic syndromes or neurological conditions; (2) a history of craniocerebral trauma; (3) diagnosed language delay, developmental delay, hearing impairment, autism, or other chronic medical condition; (4) if they were exposed to a language other than Chinese more than 20% of the time since birth. Measures Baseline clinical assessments General information survey: The self-designed “General Information Questionnaire” was used to collect demographic data from participants, including age, gender, parents’ age, education level, occupation, and annual family income. Gesell Developmental Schedules (GDS): The Gesell Developmental Schedules [ 61 ] is a standardized early developmental quotient (DQ) assessment that provides an overall index of ability on the following five subscales: adaptive behavior, gross-motor behavior, language behavior, fine-motor behavior, and personal-social behavior. All the children were administered the GDS at baseline. ADOS: The ADOS is a semi-structured, standardized diagnostic observational instrument that provides the diagnosis of ASD based on the DSM-IV algorithm. The ADOS is designed to assess autistic symptoms in subjects with ASD about communicative behaviors, social reciprocity, repetitive behaviors, and play [ 62 ]. Baseline behavior observation Parent-child interaction: Children with ASD and their partners were observed at an initial visit using a free play task. The child’s mother was always the partner, but there were also 2 fathers and 1 grandmother in the ASD group. The free play task consisted of a semi-naturalistic observation of parent-child interaction in a laboratory playroom (3 × 3 m 2 ) during which the parent sat on the floor with the child so that we could observe how the dyad interacted. During this task, a standardized set of age-appropriate toys were utilized, such as cause-and-effect toys, dolls, books, toy cars, balls, toys for imaginative play (e.g., blocks), and a small towel for peekaboo games (Fig. 1 shows an example of a free play session). The observation lasted for 13 minutes, and before the parent-child interaction began, the child was given 3 min to explore three toys selected by their parent. Then, the parent could join in to play with the child using all the toys for the next 10 minutes. Video records were made using four cameras fixed to the wall and recordings were synchronized for subsequent coding. Interaction Coding: Trained and reliable coders who were masked to the study’s hypotheses applied a coding scheme developed by Adamson et al. (2009) [ 52 ]. Interrater reliability was tested by coding 20% of the video recordings independently using Cohen’s kappa interrater agreement coefficient. Cohen’s kappa averaged 0.89 for parent and child behaviors. JE states of the parent-child interaction were rated using the Observer XT 12.0 behavioral coding software including unengaged, object engagement, supported JE, coordinated JE, and other (see Table 1 for further details). The current coding system followed a 3-s rule to avoid very brief fluctuations in attention. That is, an engagement state was defined as a period of at least 3-s characterized by the child’s active interest in people and in objects and events. Thus, if the child wandered away from the interaction for less than 3-s towards a brief fluctuation, this was not coded as an engagement state changing [ 51 ]. Table 1 Engagement state coding Engagement state Definition Unengaged Child is not engaged with a specific person or object, and may be unoccupied, scanning the environment, or flitting between different foci. Object engagement Child is exploring or playing with object(s) by him/herself. While the parent may attempt to engage the child, the child ignores him/her. This state requires active engagement with objects (i.e., does not include absent-mindedly holding a toy while scanning the room). Supported JE Parent and child are actively involved with the same object, but the child does not visually acknowledge the parent (i.e., s/he does not glance up at the parent to coordinate attention between objects and people). Coordinated JE Parent and child are actively involved with the same object, and the child coordinates their attention between objects and people, visually acknowledging the parent’s role in the interaction. Other Person engagement (i.e., child’s attention to only the parent; may include physical contact with parent but no objects) and Onlooking (i.e., child looking at the parent’s activities without being actively involved) were coded to ensure accurate distinction between categories but collapsed for analyses Uncodable Segments of the observation were considered uncodable if the movement of the child or camera gave an inadequate view of the child’s activities Assessments at follow-up At follow-up, 44 children with ASD were diagnosed according to DSM-5 diagnostic criteria and completed two standardized clinical assessments; namely, the Autism Diagnostic Observation Scale (ADOS) [ 62 ] and Autism Diagnostic Inventory-Revised (ADI-R) [ 63 ]. ADOS: which has been mentioned in section 2.2.1. ADI-R: which is a standardized, semi-structured diagnostic interview administered to caregivers. It consists of 93 questions that assess three domains of behaviors: (1) reciprocal social interaction; (2) communication and language; (3) restrictive and repetitive stereotyped interests and behaviors. Diagnosis of ASD requires a level at which all three domains must be scored beyond the cutoff value. LUI-Mandarin: The Chinese version of Language Use Inventory (LUI-Mandarin) is the first and only questionnaire available in China that evaluates the pragmatic language skills of children aged between 18–47 months. Qian et al.,[ 64 ] developed the Chinese version of LUI, and showed good reliability, validity, and developmental sensitivity of it, indicating that the LUI-Mandarin is a valid and reliable tool for Chinese toddlers and preschool children. Like the original English version of the LUI [ 65 ], the LUI-Mandarin is a parent-report measure that includes three main parts and 14 subscales. Two subscales (A and B) comprise Part 1 and assess a child’s early use of gestures. Part 2 is comprised of three subscales (C, D, and E) that assess a child’s communication at approximately the one- to two-word stage (e.g., requests for help). Nine subscales (F to N) comprise Part 3 and assess a variety of different uses of language that appear once children start to use longer sentences and adapt their conversation to others. The LUI-Mandarin mainly focuses on the use of language in social interactions rather than on vocabulary and grammar. As most LUI items do not focus on the child’s production of specific words, instead, they ask about language use more generally, followed by examples of what a young child might say. These examples are intended to help parents recognize and focus on the purpose or function of their child’s language (rather than on its form). In this paper, we refer to children’s performance on the LUI-Mandarin as their ‘pragmatic ability’. Data Analysis First, SPSS 22.0 software was used to compare the baseline variables of children between the ASD group and the TD group by independent sample t test, and the differences in the LUI Total score and each subscale score of the LUI-Mandarin between the two groups were analyzed. Second, correlation analysis was used to explore the correlation between pragmatic ability of children with ASD and autistic symptoms at follow-up, as well as structural language ability and JE states at baseline. Finally, we explored the consistent early predictors of pragmatic development of children with ASD under different regression algorithms. The baseline variables were grouped into three categories, namely, child, parent, and parent-child interaction factors. The child factors included age, gender, developmental level, and autistic symptoms. The caregiver factors included caregiver’s age, parenting stress, and education level. The factors of parent-child interaction included states of JE. Results General and demographic data of the two groups at baseline As shown in Table 2 , there were no significant differences between the two groups in terms of age, gender, caregiver age, and caregiver education level. However, compared with the TD group, caregiver parenting stress was significantly higher in the ASD group (PSI-SF total score: t = 2.655, p = 0.010, Cohen’s d = 0.704). Table 2 Demographics of participants and mean performance on GDS and PSI-SF ASD group M(SD) TD group M(SD) X 2 /t p Cohen’s d N 71 38 - - Children’s age 24.04(3.711) 22.31(4.338) 1.645 0.104 0.429 Children’s gender (M/F) 56/15 25/13 2.22 0.136 - Caregivers’ age 29.83(3.407) 31.75(4.285) -1.884 0.064 -0.496 Caregivers’ education 15.74(1.630) 15.69(1.371) 0.140 0.889 0.033 Caregivers’ PSI-SF total score 104.78(12.351) 94.65(16.169) 2.655 0.010* 0.704 GDS Adaptive behavior 78.45(20.086) Gross Motor behavior 91.69(18.764) Fine motor behavior 81.19(20.608) Language behavior 75.46(17.283) Personal-social behavior 65.96(16.165) Note: GDS༚Gesell Developmental Schedules;PSI-SF༚Parenting Stress Index, Short Form༛ * p < 0.05; Comparison of pragmatic ability between the two groups at follow-up The LUI-Mandarin was used to evaluate the pragmatic ability of children in the two groups at follow-up. The results showed that the scores of all 10 scored subscales and the corresponding summed LUI Total score in the ASD group were significantly lower than those in the TD group (subscale C-Types of words: t = -4.187, p < 0.001, Cohen’s d = -0.705; D-Requests for help: t = -4.259, p < 0.001, Cohen’s d = -0.718; F-Verbal declaratives: t = -5.723, p < 0.001, Cohen’s d = -1.043; G-Questions/comments-Things: t = -5.559, p < 0.001, Cohen’s d = -0.939; H-Questions/comments-People: t = -6.870, p < 0.001, Cohen’s d = -1.166; I-Words in activities with people: t = -6.560, p < 0.001, Cohen’s d = -1.134; J-Teasing/senses of humor: t = -3.358, p = 0.001, Cohen’s d = -0.681; K-Interest in words and language: t = -5.368, p < 0.001, Cohen’s d = -0.961; M- Adapting conversation to others: t = -5.430, p < 0.001, Cohen’s d = -0.995; N-Building sentences/stories: t = -5.509, p < 0.001, Cohen’s d = -1.025; and LUI Total score: t = -6.492, p < 0.001, Cohen’s d = -1.124)。Figure 2 shows the comparison of the scores on the 10 subscales and the LUI Total score between the two groups of children (for comparison purposes, the subscale scores were transformed by dividing the actual score by the highest score). Association between symptom severity and pragmatic ability at follow-up in children with ASD The standardized assessment tools ADOS and ADI-R were used to measure the severity of symptoms in the ASD group at follow-up (n = 44), and the P values of the normal K-S test for all symptom dimensions were above 0.05, which was consistent with the normal distribution. As shown in Fig. 3 , partial correlation analysis showed that at follow-up, the LUI-Mandarin Total score in the ASD group was significantly negatively correlated with ADOS subscales: ADOS (communicative behaviors) ( r = -0.792, p < 0.001), ADOS (social reciprocity) ( r = -0.811, p < 0.001), ADOS (play) ( r = -0.849, p < 0.001), ADOS (repetitive behaviors) ( r = -0.668, p < 0.001). Figure 4 shows the correlation between the LUI-Mandarin Total score and ADI-R subscales: ADI-R (social) ( r = -0.761, p < 0.001), ADI-R (communication) ( r = -0.498, p = 0.001), ADI-R (repetitive behaviors) ( r = -0.565, p < 0.001), ADI-R (onset) ( r = -0.466, p = 0.002). Association between preschool pragmatic ability and baseline levels of GDS and JE in children with ASD Correlation analysis was used to explore the correlation between LUI-Mandarin Total score at follow-up (n = 71) and baseline GDS (language behavior) and JE states in children with ASD. Except for GDS (language behavior), the normal K-S test P values of all JE levels were all below 0.05, not in line with the normal distribution. As shown in Figure. 5, Pearson correlation analysis showed that the LUI-Mandarin Total score was significantly positively correlated with baseline GDS (language behavior) ( r = 0.555, p < 0.001). Spearman correlation analysis showed that the LUI-Mandarin Total score was significantly negatively correlated with UE ( r = -0.295, p = 0.012) and positively correlated with SJE ( r = 0.591, p < 0.001), but had no significant correlation with OE ( r = -0.175, p = 0.145) and CJE ( r = 0.222, p = 0.063) at baseline. Regression analysis of early predictors of preschool pragmatic ability in children with ASD Figure 6 shows comparison of significant predictors of later pragmatic ability (LUI-Mandarin Total score) under different regression algorithms in the ASD group. The SR-based analysis showed that the R 2 of the model was 0.483, and each factor explained 48.3% of the variation in pragmatic ability. The model passed the F test ( F = 15.387, P = 0.000). The factors that had a significant positive impact on pragmatic ability were GDS (language behavior): B = 0.553, t = 2.212, P = 0.030; SJE: B = 92.417, t = 3.705, P = 0.000; OE: B = 50.733, t = 2.501, P = 0.015. ADOS (social reciprocity) had a significant negative impact on pragmatic ability: B = -3.531, t = -2.408, P = 0.019. The RR-based analysis showed that the model passed the F-test ( F = 2.719, P = 0.002) when K value = 0.99 was selected for analysis combined with ridge trace map. The R 2 of the model was 0.503 and each factor explained 50.3% of the variation in pragmatic ability, The adjusted R 2 was 0.318, and the RMSE of the model error was 35.248. The factor that had a significant positive impact on pragmatic ability was GDS (language behavior): B = 0.236, t = 2.478, P = 0.017; SJE: B = 24.757, t = 3.556; P = 0.001. The factor that had a significant negative impact on pragmatic ability was ADOS (social reciprocity): B = -1.339, t = -2.162, P = 0.035; and UE: B = -24.299, t = -2.644, P = 0.011. The LR-based analysis method showed that combined with the trajectory map, K value = 0.99 was selected for analysis, and the model passed the F test ( F = 1.973, P = 0.028). The R 2 of the model was 0.424, each factor can explain 42.4% of the variation in pragmatic ability. The adjusted R 2 was 0.209, and the RMSE of the model error was 37.966. The factors that had a significant positive impact on pragmatic ability included GDS (language behavior): B = 0.423, t = 4.122, P = 0.000; SJE: B = 29.178, t = 3.891, P = 0.000. ADOS (social reciprocity) had a significant negative impact on pragmatic ability: B = -2.154, t = -3.229, P = 0.002. In addition, analysis based on PLSR showed that the R 2 of the model was 0.566, each factor could explain 56.6% of the variation of pragmatic ability. The RMSE of the model error was 32.96. SJE: B = 51.532, t = 3.368, P = 0.001, indicating that it had a significant positive impact on pragmatic ability. UE: B = -47.659, t =-2.064, P = 0.043, indicating that it had a significant negative impact on pragmatic ability. Discussion The current 3-year longitudinal study examined preschool-age pragmatic ability as assessed via the LUI-Mandarin parent-report measure in children with ASD and TD children and very early predictors thereof. A clinician-rated parent-child play interaction measure was used to assess JE functioning in the ASD group. Regardless of gender and age, TD children tended to exhibit better pragmatic ability than children with ASD, and worse pragmatic ability in children with ASD were correlated with higher levels of autism symptomatology on the ADOS and ADI administered at the preschool-age time point. Moreover, this study extends previous studies documenting long-term associations between JA and subsequent language skills in ASD by demonstrating associations between 24-month JE and pragmatic ability at 5 ~ 6 years of age. Many of the studies exploring pragmatic ability in children with ASD have employed questionnaires to evaluate language use in social contexts. One of the most widely used instruments is the Children’s Communication Checklist Second Edition (CCC-2) [ 66 ]. For example, Baixaiuli-Fortea et al. (2019) [ 14 ] showed pragmatic impairment in children with ASD aged 7–11 years as evidenced in difficulties in conversation initiation, context use, non-verbal communication and use of stereotyped language as measured by the CCC-2. Similar findings using the CCC-2 were reported by Kuijper et al. (2017) [ 67 ] among children with ASD and TD children aged 6–12 years. These studies suggest that children with ASD are at elevated likelihood for delays in pragmatic ability by school-age. However, it remains unclear when the delays emerge. Since pragmatic ability have been shown to be important to multiple developmental outcomes [ 22 , 25 ], identifying early pragmatic language weaknesses might be important for children with ASD to avoid negative outcomes. Our results showed significantly lower scores on all subscales of the LUI-Mandarin, and its Total score, in our preschool-aged ASD group compared with our TD group. Similar results have been reported in a recent study establishing the discriminative validity of LUI-Mandarin [ 64 ]. In addition, similar findings to ours were reported by Miller et al [ 17 ] who used the English LUI to assess early pragmatic ability in siblings of children with ASD compared to TD children. They found that at 36 months, the pragmatic ability of siblings of children with ASD was significantly lower than that of the TD children, and the proportion of children with pragmatic language impairment (PLI; defined as LUI scores falling at or below the 10th percentile) in the sibling with ASD group was significantly higher than that in the TD group (35% vs 10%). These findings indicate that pragmatic difficulties are exhibited early in preschool age, suggesting the need to strengthen early assessment and identification of pragmatic difficulties in children with ASD. We explored the associations between pragmatic ability and autism symptomatology as captured by the ADOS and ADI-R in children with ASD. Miller et al also used the LUI to measure pragmatic ability and found significantly higher ADOS scores in their PLI group relative to those without PLI, indicating that children with parent-rated PLI also had greater examiner-rated impairment in social communication [ 17 ]. The consistency between different assessment methods supports the validity of LUI and emphasizes close correlation between the pragmatic ability as per parent report vs directly administered tests. However, restricted, and repetitive behaviors (RRBs) were not examined in Miller et al’s study, and so whether those children with PLI also showed higher levels of RRBs remains unknown [ 17 ]. Ray-Subramanian et al. (2012) [ 68 ] however, did find that expressive and receptive language were significantly negatively correlated with RRBs in children with ASD at 3 years of age. Notably, our study found that, in addition to expressive and receptive language, a significant negative correlation was found between pragmatic ability and RRBs in preschool children with ASD, contributing a new finding to previous studies. Future research is needed to understand the relationship between pragmatic language and RRBs as well as the underlying mechanism. An important finding of the present study was that the proportion of SJE in early parent-child interaction is closely related to later pragmatic ability, and regression analysis also confirmed that, regardless of the algorithms, SJE was the most valuable predictor of future pragmatic ability in children with ASD. Consistent with our finding, Adamson et al. [ 49 ] showed that language outcomes of children with ASD were related to the frequency of SJE, but not closely related to CJE. The language outcomes they discussed were in the category of structural language, whereas our study focused on the pragmatic language outcome of children with ASD. A study by Shih et al. (2021) [ 69 ] investigated the mediating effect of SJE on the effect of IJA intervention, and the importance of IJA on expressive and receptive language in children with ASD. They found that SJE significantly mediated 69% of the effect of IJA intervention, and IJA was a predictor of later expressive and receptive language skills. These findings suggest that increasing the proportion of SJE during parent-child interaction is a potential intervention for IJA improvement, that could also further improve the language skills in children with ASD. However, more research is needed to further explore the relationship between early SJE skills, IJA skills and later pragmatic ability in children with ASD. In addition, our correlation and regression analyses also showed that early structural language ability was an important factor affecting later pragmatic language outcomes in children with ASD. Matthews et al. (2018) [ 70 ] reviewed research regarding the association between pragmatic ability and three important factors including structural language, theory of mind and executive function in children with typical and atypical development, and found that the correlation between pragmatic language and structural language was the most consistent. Similarly, a review by Boucher (2012) [ 71 ] also showed that pragmatic language outcomes were most affected by the structural language in children with ASD. In addition, previous studies have shown that structural language are intertwined with pragmatic language (including metaphor comprehension [ 56 ], idiomatic language [ 57 ], and context disambiguation [ 72 ]. Studies have also shown that improving structural language can benefit children with ASD with pragmatic difficulties [ 58 ]. Limitations of this study The present study has several strengths, including the focus on both maternal and child characteristics at baseline as well as the analysis of video-recorded parent-child interactions and the use of multiple regression algorithms providing different advantages. However, this study also has several limitations. First, pragmatic language and structural language abilities are intertwined rather than fully distinct and autonomous systems, so it’s hard to really separate them. Second, although parent-report measures enable a more comprehensive assessment of a young child’s pragmatic language competence, a full picture of a child’s pragmatic language requires multiple types of assessments [ 73 ], future research could additionally assess children’s pragmatic abilities in natural contexts where these skills can be directly observed in real time [ 74 ]. Third, at follow-up only a smaller subset of the enrolled children with ASD underwent clinical diagnosis and were administered the standardized ADOS and ADI-R assessments. This smaller sample size limits the generalizability of results examining the association between levels of autistic symptomatology and pragmatic ability. Conclusions The present study provides evidence of pragmatic language difficulties in preschool children with ASD and, moreover, a gradient effect in that the greater the difficulties in pragmatic ability, the greater the severity of autistic symptoms. Further, results indicated that early SJE and structural language were important predictors of later pragmatic ability. We suggest as a result that early intervention targeting these abilities may be critical for promoting successful pragmatic communication outcomes for children with ASD. Declarations Ethics approval and consent to participate This study was approved by the Nanjing Brain Hospital affiliated with the Nanjing Medical University Ethics Committee, participants were consented by an informed consent process that was reviewed by the Ethics Committee of Nanjing Medical University and certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki, and informed consent was obtained from the parents or legal guardians of the participants. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors (Lu Qian, Ning Ding, Hui Fang, Ting Xiao, Bei Sun, HuiYun Gao, XiaoYan Ke) declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding This work was supported by the National Key Research and Development Program of China (2016YFC1306200), the National Natural Science Foundation of China (81771478) and the “Special disease cohort” Research Project of Nanjing Medical University (NMUC2018010A). Authors’ contributions Conceived and designed the research: X-y K. Wrote the paper: LQ. Collected the data: ND, HF, TX, BS, H-y G. Analyzed the data: LQ. Revised the paper: X–y K and LQ. The authors read and approved the final manuscript. Acknowledgements We are thankful for the support of the fundings, and acknowledge the participants and their families for their support, as they made this study possible. We also extend thanks to Dr. Daniela K. O’Neill, who provided guidance and advice on the draft and revised the draft. References American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). Washington, DC: American Psychiatric Pub; 2013. Chaste P, Leboyer M. 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Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Jan, 2025 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 11 Nov, 2024 Reviews received at journal 10 Nov, 2024 Reviews received at journal 09 Oct, 2024 Reviewers agreed at journal 07 Oct, 2024 Reviewers agreed at journal 30 Sep, 2024 Reviewers invited by journal 22 Jul, 2024 Editor invited by journal 11 Jul, 2024 Editor assigned by journal 10 Jul, 2024 Submission checks completed at journal 10 Jul, 2024 First submitted to journal 08 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4703774","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":332534371,"identity":"42b52fe6-a3f4-4252-bc96-3472cd71e062","order_by":0,"name":"Lu Qian","email":"","orcid":"","institution":"Nanjing Brain Hospital affiliated with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lu","middleName":"","lastName":"Qian","suffix":""},{"id":332534372,"identity":"b1beafb4-0373-4ce6-9d8e-7a47ebef4385","order_by":1,"name":"Ning Ding","email":"","orcid":"","institution":"Nanjing Brain Hospital affiliated with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ning","middleName":"","lastName":"Ding","suffix":""},{"id":332534373,"identity":"82f21689-b2fc-47f6-9b5b-07d3ad382157","order_by":2,"name":"Hui Fang","email":"","orcid":"","institution":"Nanjing Brain Hospital affiliated with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hui","middleName":"","lastName":"Fang","suffix":""},{"id":332534374,"identity":"1093d23a-8ddd-4551-8e18-0323b181125c","order_by":3,"name":"Ting Xiao","email":"","orcid":"","institution":"Nanjing Brain Hospital affiliated with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ting","middleName":"","lastName":"Xiao","suffix":""},{"id":332534375,"identity":"2763a962-4ef6-4658-b2df-67099f868192","order_by":4,"name":"Bei Sun","email":"","orcid":"","institution":"Nanjing Brain Hospital affiliated with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Bei","middleName":"","lastName":"Sun","suffix":""},{"id":332534376,"identity":"d674b2ac-6a62-4d19-aca2-b322844870f9","order_by":5,"name":"HuiYun Gao","email":"","orcid":"","institution":"Nanjing Brain Hospital affiliated with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"HuiYun","middleName":"","lastName":"Gao","suffix":""},{"id":332534377,"identity":"92751c06-9e1c-47af-bf15-bab9fcfa0f17","order_by":6,"name":"XiaoYan Ke","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYBACCSA+AGaxNzAYgBkHiNbCc4AELVBWApRBSItke4/hgR8Vh+XNJd8eKLrZxiDHdyOB8XMBHi3SPMcSDvacOWy4c3ZegnFuG4Ox5I0EZukZeLTISSQfOMDbdphxw+0cA5CWxA03EtiYefBpkX/YcPBv22H7DTfPgLXUE9QiLcF84DDQFqDhPGAtCQaEtEj2pCUcljmTnrzhDNBhOeckDGeeedgsjU+LxPEzxh/fVFjbbjh+xsw4p8xGnu948sHP+LRAQTOIYDOAxBNjA2ENDAx1IIL5ATFKR8EoGAWjYOQBAJDGUE9PNX0WAAAAAElFTkSuQmCC","orcid":"","institution":"Nanjing Brain Hospital affiliated with Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"XiaoYan","middleName":"","lastName":"Ke","suffix":""}],"badges":[],"createdAt":"2024-07-08 08:16:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4703774/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4703774/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-024-06452-1","type":"published","date":"2025-01-20T15:57:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62156559,"identity":"32c6f522-f9b9-450c-a665-f8a5ab90dc75","added_by":"auto","created_at":"2024-08-09 21:09:21","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":238084,"visible":true,"origin":"","legend":"\u003cp\u003eThis figure provides an example of a free play session (photos provided with permission of parent).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4703774/v1/7465d5d0b2bd8310acf902e2.jpeg"},{"id":62156562,"identity":"a9bf4510-c227-4612-b7c5-c6839ec12b8b","added_by":"auto","created_at":"2024-08-09 21:09:21","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":76704,"visible":true,"origin":"","legend":"\u003cp\u003eComparation of the 71 children in ASD and 38 age- and sex-matched TD group on 10 scored subscales and LUI-Mandarin Total score.\u003c/p\u003e\n\u003cp\u003eNote: C: Types of words; D: Requests for help; F: Verbal declaratives; G: Questions/comments-Things; H: Questions/comments-People; I: Words in activities with people; J: Teasing/senses of humor; K: Interest in words and language; M: Adapting conversation to others; N: Building sentences/stories\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4703774/v1/a456f33c1e59f59a248988fd.jpeg"},{"id":62156558,"identity":"0444ff4e-4a9a-4964-a134-bad250da6553","added_by":"auto","created_at":"2024-08-09 21:09:21","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":97136,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelations between LUI-Mandarin Total score and ADOS subscale scores at follow-up in the ASD group (n=44)\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4703774/v1/cfbb871e0900293dd253928f.jpeg"},{"id":62156563,"identity":"ef81837c-7623-4703-820c-e6623a2566c2","added_by":"auto","created_at":"2024-08-09 21:09:21","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":97757,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelations between LUI-Mandarin Total score and ADI-R subscale scores at follow-up in the ASD group (n=44)\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4703774/v1/30c7239c44946d6b8344d75c.jpeg"},{"id":62156561,"identity":"1f14050d-db66-4770-ae8d-fd912435d6f8","added_by":"auto","created_at":"2024-08-09 21:09:21","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":66410,"visible":true,"origin":"","legend":"\u003cp\u003eSignificant correlations between LUI-Mandarin Total score and Gesell subscale (language behavior) as well as JE levels at baseline in the ASD group (n= 71)\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4703774/v1/6dd5f10438d97a03b170b277.jpeg"},{"id":62157362,"identity":"ea77a563-7ca6-4b75-abfb-101fe7d0b649","added_by":"auto","created_at":"2024-08-09 21:17:21","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":186079,"visible":true,"origin":"","legend":"\u003cp\u003eWeight of significant predictors of pragmatic ability under different regression algorithms in the ASD group (n= 71)\u003c/p\u003e\n\u003cp\u003eNote: stepwise regression (SR), ridge regression (RR), lasso regression (LR) and partial least squares regression (PLSR)\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-4703774/v1/e203be4f411b34cfb56a2306.png"},{"id":74858364,"identity":"73a38519-d992-4318-aedb-12cfd0eda618","added_by":"auto","created_at":"2025-01-27 16:08:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1775210,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4703774/v1/8e7348ab-fd12-441a-ada4-8a90031f6007.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pragmatics performance, the relation to symptom severity, and early clinical predictors of pragmatics in 5~6-year-old children with autism spectrum disorder","fulltext":[{"header":"Background","content":"\u003cp\u003eAutism spectrum disorder (ASD) is an early onset neurodevelopmental disorder characterized by deficits in social communication, social interaction and restricted/repetitive behaviors or interests, which seriously affect the patient's social, academic, family, and other aspects [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. To date, the etiology of ASD is unclear. It is believed that the pathogenesis of ASD is a result of an interaction of genetics and environment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A recent Chinese multi-center study estimated that the prevalence of ASD is as high as 0.7%, with a male to female ratio of about 3:1 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. At present, the diagnosis of ASD is mainly based on behavioral manifestations. Although there is great heterogeneity between and within individuals, the core characteristics of ASD can still be reliably identified [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although in the United States, the median age of ASD diagnosis remains stubbornly at 4 to 5 years [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], early warning signs can be observed in infancy [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Longitudinal studies of individuals with ASD have identified high-risk behaviors such as poor eye contact, lack of visual tracking, failure to respond to names, poor imitation skills, lack of social interest, and limited language ability [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Studying the early behavioral signs of individuals with ASD is the first step toward early identification, referral, diagnosis, and intervention. A growing number of studies support the efficacy of early behaviorally based interventions in ASD for the improvement of social communication and behavioral functioning to varying degrees [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003ePragmatic language and ASD‑related characteristics\u003c/h2\u003e \u003cp\u003ePragmatic language refers to the ability to use spoken language to effectively convey information in different social contexts [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], which is frequently demonstrated to be a key component of the difficulties exhibited by individuals with ASD [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] .The new DSM-5 diagnosis of Social (Pragmatic) Communication Disorder (SPCD) also aims to identify individuals with pragmatic disorders. Because pragmatic language depends on more sophisticated developments of speech and language among other factors, a formal diagnosis of SPCD is rarely made in children younger than 4 years of age, although difficulties and delays in social (pragmatic) communication can be assessed and identified prior to this age [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Indeed, early signs of ASD may involve early pragmatic communication such as non-typical use and understanding of gestures, and differences in attention to social peers and common topics. In addition, about 30% of the individuals with ASD can only obtain minimal language communication with age [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. With respect to those who have developed spoken language, pragmatic difficulties often persist, characterized by difficulties in the attempt to communicate and narrow communicative behaviors [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Moreover, pragmatic language difficulties may persist into adolescence and adulthood in ASD, as evidenced by poor topic management during conversation, frequent appearance of off-topic information, unusual rhythm in speech, reduced social reciprocity and response to social cues from peers [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Studies have shown that the effects of pragmatic impairments are far-reaching, and found to be associated with a greater incidence of behavioral problems, especially destructive and externalizing behaviors [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Among children, the long-term negative effects of pragmatic impairments include poor peer relations [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], being excluded and rejected by peers in school [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and having difficulties forming successful social relations in adulthood [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMiranda et al [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] examined the relationships between the social communication questionnaire (SCQ) domains (including reciprocal social interaction, communication, and restricted and repetitive behaviors (RRBs)) and pragmatic language controlling for sex and vocabulary in children with ASD, and showed that the SCQ reciprocal social interaction domain correlated significantly with the pragmatic index, whereas there was no significant relationship with RRBs. However, previous studies have examined the association between the degree and type of RRBs and levels of functioning in ASD, showing that children with higher levels of RRBs were more likely to present with less developed receptive and expressive language abilities, and lower adaptive communication and socialization skills [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eJoint attention and pragmatic language\u003c/h3\u003e\n\u003cp\u003eEvidence of brain development and key stages of neural plasticity in infancy lends strong support to the importance of early intervention [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Studies have shown that early intervention is efficacious in modifying cognitive and social-communicative outcomes and potentially improving developmental trajectories in toddlers with ASD [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Longitudinal studies of ASD can help understand the association between early developmental trajectories and outcomes, and provide benchmarks for early interventions.\u003c/p\u003e \u003cp\u003eJoint attention (JA) is a tertiary interactive process composed of two social partners and an object, and is an important component in the development of early social communication in typically-developing infants [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. JA is often defined by measures that assess a discrete set of children\u0026rsquo;s skills using structured tasks (i.e., whether an infant can use pointing and eye gaze to share attention to an object). As early as 6 months of age, infants\u0026rsquo; gaze can follow the caregiver to a new location [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and, by 12 months of age, they can establish JA in various ways, such as looking at the caregiver and the object alternately, reaching for the object, or lifting the object to show to others [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These behaviors can help them build shared concerns for an object or event with social partners [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Difficulties with JA occur in ASD from infancy, and they are often one of the earliest signs accompanying a diagnosis of ASD [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. There are two types of JA: response to joint attention (RJA) and initiation of joint attention (IJA). RJA is considered a more involuntary process of attention following, which can be improved to a certain extent with the development in individuals with ASD, whereas IJA is considered a more active process to share an experience, which shows little change with age in individuals with ASD [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. RJA and IJA are both critical for the development of language in early childhood, especially for ASD [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] When children engage in JA, they engage in a social situation that helps to associate words with meaning and develop interactive abilities [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral prospective studies have investigated the correlation between early JA levels and later pragmatic abilities in children at risk for ASD. For example, in 2015, Gillespie-Lynch et al. (2015) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] evaluated JA levels in high-risk children with ASD at 12 and 18 months and explored the relationship between early JA levels and children\u0026rsquo;s pragmatic and structural language abilities 6 years later. Their results showed that response to joint attention (RJA) at 18 months of age could predict structural language but not pragmatic language in high-risk children with ASD. Greenslade et al. (2019) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] collected social and language data in children at risk for ASD from 14 to 36 months old, and evaluated their pragmatic levels using the Pragmatic Rating Scale-School-age (PRS-SA) adapted from the PRS [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] from 8 to 12 years old. They found that the JA levels at 14 months of age could predict later pragmatic abilities in children at risk for ASD at school age.\u003c/p\u003e\n\u003ch3\u003eJoint engagement and pragmatic language\u003c/h3\u003e\n\u003cp\u003ePrevious studies have mainly focused on the importance of early JA for pragmatic language development, especially for siblings of children with ASD[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. However, neurotypical infants rarely look at the caregivers\u0026rsquo; faces before attending to an object during social interactions in reality [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], and children with ASD may engage with others in ways that are not captured in standard measures of JA [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. In contrast, rather than assessing discrete skills, joint engagement (JE) is evaluated with respect to mutual and extended caregiver-child interactions in which a child and social partner sustain active involvement in the context of toy play [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. JE may be more practical for interventions than JA because JE focuses on the interaction between caregiver and child, whereas JA is more relevant to objects and events. Interventions can be designed around promoting JE between caregiver and child [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The importance of JE was confirmed by a recent study showing that JE was a major predictor of expressive language even when JA was considered[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Adamson distinguished between three types of JE: (1) Coordinated JE (CJE), the most developmentally advanced periods, which requires the infant to make eye contact with the social partner; (2) Supported JE (SJE), a state in which the infant is actively involved with the same object as the social partner without making eye contact; and, (3) Object Engagement (OE), in which the infant is exclusively engaged with objects and not with the social partner[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. For typically developing (TD) children, SJE accounted for a large proportion of play during the first two years of life, and by the age of 12 months, CJE began to appear, with an increase at the age of 24 months [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Children with ASD aged 2 to 3 years had a lower proportion of CJE and spent more time involved in OE than age and speech level matched TD children [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. However, children with ASD had a higher proportion of SJE in parent-child play interactions, compared to their TD peers [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Studies have shown that the language outcome of children with ASD is related to the frequency of SJE, but not closely related to CJE. One possible explanation might be that the frequency of CJE is lower than that of SJE, and it almost does not occur in the communicative interactions between children with ASD and their caregivers [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eStructural language and pragmatic language\u003c/h3\u003e\n\u003cp\u003eThe form (such as phonology, vocabulary, and syntax) and content (semantics) of language represent structural language. Pragmatic language needs to be expressed through structural language and social context, and structural language is a key element of pragmatic language. Pragmatic language is closely related to structural language, supported by studies that have shown that deficits in structural language are common in children with ASD and are related to pragmatic impairment [\u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. In addition, studies have shown that structural language is a key predictor of non-literal pragmatic forms of language use such as idioms and metaphors [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Also, a meta-analysis showed that when the ASD group was matched with the TD group in terms of structural language performance, no significant difference was found in performance on pragmatic tasks [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. To summarize, these studies suggest the importance of structural language to pragmatic language.\u003c/p\u003e\n\u003ch3\u003eCurrent study\u003c/h3\u003e\n\u003cp\u003eIn neurotypical development, early JA, broader social-communication behaviors (e.g., shared enjoyment, gesture use), and structural language are the theoretical precursors of advanced social cognition. Social cognitive skills, as well as the ability to combine appropriate vocabulary and nonverbal communication behaviors in efficient well-formed expressive messages, are critical to later effective pragmatic communication [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Although the effects of the above factors on pragmatic outcomes have been studied separately, they have not been jointly studied as predictors of pragmatic language in the same model in children with ASD. Thus, the relative contribution of early predictors of pragmatic development - JA and especially JE and/or structural language - in ASD is unclear. Therefore, the current study examined pragmatic communication functioning in preschool-age children with ASD and TD controls, as well as the association with autistic symptoms and the early predictors of this functioning in the ASD sample. The following research hypotheses were addressed. First, between-group differences in pragmatic communication functioning at preschool years were examined, comparing the ASD group and TD controls. More specifically, TD controls were hypothesized to demonstrate significantly better preschool-age pragmatic communication functioning than the ASD group. Second, correlations between preschool-age pragmatic communication and autistic symptoms were expected to be significant when conducted with the ASD sample. Finally, in regression models, the combined set of 24-month frequency of joint engagement and structural language abilities were expected to explain a significant amount of the variance in later pragmatic communication in the ASD sample.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eIn total, 71 children with ASD (56 boys and 15 girls) and 38 TD controls (25 boys and 13 girls) ranging in age between 23 and 30 months were enrolled in this study. All participants completed the general condition scale, parenting stress survey and developmental assessment at the time of enrollment. Three years later (around the age of 5 to 5.5 years), totally 44 of the 71 children with ASD received diagnostic assessment, while all participants received pragmatic language assessment.\u003c/p\u003e \u003cp\u003eFor the patient group, inclusion criteria included: (1) participants were enrolled from a cohort study on ASD from October 2017; (2) the Modified Checklist for Autism in Toddlers (M-CHAT) for the participants was positive; (3) participants were diagnosed according to DSM-5 by two attending child psychiatrists or above, and met the core symptoms of ASD diagnostic criteria, but the age was less than 36 months. Exclusion criteria were as follows: (1) participants with any other diagnosed genetic syndromes or neurological conditions; (2) premature children and those with complications after birth; (3) a history of craniocerebral trauma; (4) chronic medical conditions; (5) visual or hearing impairments; (6) if they were exposed to a language other than Chinese more than 20% of the time since birth.\u003c/p\u003e \u003cp\u003eIn recruiting the TD group, participants with comparable general demographic data such as age and gender were sought. Exclusion criteria for the TD group were as follows: (1) any genetic syndromes or neurological conditions; (2) a history of craniocerebral trauma; (3) diagnosed language delay, developmental delay, hearing impairment, autism, or other chronic medical condition; (4) if they were exposed to a language other than Chinese more than 20% of the time since birth.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eBaseline clinical assessments\u003c/h2\u003e \u003cp\u003eGeneral information survey: The self-designed \u0026ldquo;General Information Questionnaire\u0026rdquo; was used to collect demographic data from participants, including age, gender, parents\u0026rsquo; age, education level, occupation, and annual family income.\u003c/p\u003e \u003cp\u003eGesell Developmental Schedules (GDS): The Gesell Developmental Schedules [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] is a standardized early developmental quotient (DQ) assessment that provides an overall index of ability on the following five subscales: adaptive behavior, gross-motor behavior, language behavior, fine-motor behavior, and personal-social behavior. All the children were administered the GDS at baseline.\u003c/p\u003e \u003cp\u003eADOS: The ADOS is a semi-structured, standardized diagnostic observational instrument that provides the diagnosis of ASD based on the DSM-IV algorithm. The ADOS is designed to assess autistic symptoms in subjects with ASD about communicative behaviors, social reciprocity, repetitive behaviors, and play [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBaseline behavior observation\u003c/h2\u003e \u003cp\u003eParent-child interaction: Children with ASD and their partners were observed at an initial visit using a free play task. The child\u0026rsquo;s mother was always the partner, but there were also 2 fathers and 1 grandmother in the ASD group. The free play task consisted of a semi-naturalistic observation of parent-child interaction in a laboratory playroom (3 \u0026times; 3 m\u003csup\u003e2\u003c/sup\u003e) during which the parent sat on the floor with the child so that we could observe how the dyad interacted. During this task, a standardized set of age-appropriate toys were utilized, such as cause-and-effect toys, dolls, books, toy cars, balls, toys for imaginative play (e.g., blocks), and a small towel for peekaboo games (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows an example of a free play session). The observation lasted for 13 minutes, and before the parent-child interaction began, the child was given 3 min to explore three toys selected by their parent. Then, the parent could join in to play with the child using all the toys for the next 10 minutes. Video records were made using four cameras fixed to the wall and recordings were synchronized for subsequent coding.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eInteraction Coding: Trained and reliable coders who were masked to the study\u0026rsquo;s hypotheses applied a coding scheme developed by Adamson et al. (2009) [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Interrater reliability was tested by coding 20% of the video recordings independently using Cohen\u0026rsquo;s kappa interrater agreement coefficient. Cohen\u0026rsquo;s kappa averaged 0.89 for parent and child behaviors. JE states of the parent-child interaction were rated using the Observer XT 12.0 behavioral coding software including unengaged, object engagement, supported JE, coordinated JE, and other (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for further details). The current coding system followed a 3-s rule to avoid very brief fluctuations in attention. That is, an engagement state was defined as a period of at least 3-s characterized by the child\u0026rsquo;s active interest in people and in objects and events. Thus, if the child wandered away from the interaction for less than 3-s towards a brief fluctuation, this was not coded as an engagement state changing [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEngagement state coding\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEngagement state\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnengaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChild is not engaged with a specific person or object, and may be unoccupied, scanning the environment, or flitting between different foci.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObject engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChild is exploring or playing with object(s) by him/herself. While the parent may attempt to engage the child, the child ignores him/her. This state requires active engagement with objects (i.e., does not include absent-mindedly holding a toy while scanning the room).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupported JE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParent and child are actively involved with the same object, but the child does not visually acknowledge the parent (i.e., s/he does not glance up at the parent to coordinate attention between objects and people).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoordinated JE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParent and child are actively involved with the same object, and the child coordinates their attention between objects and people, visually acknowledging the parent\u0026rsquo;s role in the interaction.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerson engagement (i.e., child\u0026rsquo;s attention to only the parent; may include physical contact with parent but no objects) and Onlooking (i.e., child looking at the parent\u0026rsquo;s activities without being actively involved) were coded to ensure accurate distinction between categories but collapsed for analyses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUncodable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSegments of the observation were considered uncodable if the movement of the child or camera gave an inadequate view of the child\u0026rsquo;s activities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAssessments at follow-up\u003c/h2\u003e \u003cp\u003eAt follow-up, 44 children with ASD were diagnosed according to DSM-5 diagnostic criteria and completed two standardized clinical assessments; namely, the Autism Diagnostic Observation Scale (ADOS) [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] and Autism Diagnostic Inventory-Revised (ADI-R) [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eADOS: which has been mentioned in section 2.2.1.\u003c/p\u003e \u003cp\u003eADI-R: which is a standardized, semi-structured diagnostic interview administered to caregivers. It consists of 93 questions that assess three domains of behaviors: (1) reciprocal social interaction; (2) communication and language; (3) restrictive and repetitive stereotyped interests and behaviors. Diagnosis of ASD requires a level at which all three domains must be scored beyond the cutoff value.\u003c/p\u003e \u003cp\u003eLUI-Mandarin: The Chinese version of Language Use Inventory (LUI-Mandarin) is the first and only questionnaire available in China that evaluates the pragmatic language skills of children aged between 18\u0026ndash;47 months. Qian et al.,[\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] developed the Chinese version of LUI, and showed good reliability, validity, and developmental sensitivity of it, indicating that the LUI-Mandarin is a valid and reliable tool for Chinese toddlers and preschool children. Like the original English version of the LUI [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e], the LUI-Mandarin is a parent-report measure that includes three main parts and 14 subscales. Two subscales (A and B) comprise Part 1 and assess a child\u0026rsquo;s early use of gestures. Part 2 is comprised of three subscales (C, D, and E) that assess a child\u0026rsquo;s communication at approximately the one- to two-word stage (e.g., requests for help). Nine subscales (F to N) comprise Part 3 and assess a variety of different uses of language that appear once children start to use longer sentences and adapt their conversation to others. The LUI-Mandarin mainly focuses on the use of language in social interactions rather than on vocabulary and grammar. As most LUI items do not focus on the child\u0026rsquo;s production of specific words, instead, they ask about language use more generally, followed by examples of what a young child might say. These examples are intended to help parents recognize and focus on the purpose or function of their child\u0026rsquo;s language (rather than on its form). In this paper, we refer to children\u0026rsquo;s performance on the LUI-Mandarin as their \u0026lsquo;pragmatic ability\u0026rsquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eFirst, SPSS 22.0 software was used to compare the baseline variables of children between the ASD group and the TD group by independent sample t test, and the differences in the LUI Total score and each subscale score of the LUI-Mandarin between the two groups were analyzed. Second, correlation analysis was used to explore the correlation between pragmatic ability of children with ASD and autistic symptoms at follow-up, as well as structural language ability and JE states at baseline. Finally, we explored the consistent early predictors of pragmatic development of children with ASD under different regression algorithms. The baseline variables were grouped into three categories, namely, child, parent, and parent-child interaction factors. The child factors included age, gender, developmental level, and autistic symptoms. The caregiver factors included caregiver\u0026rsquo;s age, parenting stress, and education level. The factors of parent-child interaction included states of JE.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eGeneral and demographic data of the two groups at baseline\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, there were no significant differences between the two groups in terms of age, gender, caregiver age, and caregiver education level. However, compared with the TD group, caregiver parenting stress was significantly higher in the ASD group (PSI-SF total score: \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.655, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010, Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.704).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of participants and mean performance on GDS and PSI-SF\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eASD group\u003c/p\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTD group\u003c/p\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e/t\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCohen\u0026rsquo;s d\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eChildren\u0026rsquo;s age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.04(3.711)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.31(4.338)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.645\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.429\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eChildren\u0026rsquo;s gender (M/F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25/13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCaregivers\u0026rsquo; age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.83(3.407)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.75(4.285)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.884\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.496\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCaregivers\u0026rsquo; education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.74(1.630)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.69(1.371)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCaregivers\u0026rsquo; PSI-SF total score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104.78(12.351)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.65(16.169)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.655\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.010*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdaptive behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.45(20.086)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGross Motor behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.69(18.764)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFine motor behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.19(20.608)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLanguage behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.46(17.283)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersonal-social behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.96(16.165)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: GDS༚Gesell Developmental Schedules;PSI-SF༚Parenting Stress Index, Short Form༛\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eComparison of pragmatic ability between the two groups at follow-up\u003c/h2\u003e \u003cp\u003eThe LUI-Mandarin was used to evaluate the pragmatic ability of children in the two groups at follow-up. The results showed that the scores of all 10 scored subscales and the corresponding summed LUI Total score in the ASD group were significantly lower than those in the TD group (subscale C-Types of words: \u003cem\u003et\u003c/em\u003e = -4.187, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -0.705; D-Requests for help: \u003cem\u003et\u003c/em\u003e = -4.259, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -0.718; F-Verbal declaratives: \u003cem\u003et\u003c/em\u003e = -5.723, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -1.043; G-Questions/comments-Things: \u003cem\u003et\u003c/em\u003e = -5.559, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -0.939; H-Questions/comments-People: \u003cem\u003et\u003c/em\u003e = -6.870, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -1.166; I-Words in activities with people: \u003cem\u003et\u003c/em\u003e = -6.560, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -1.134; J-Teasing/senses of humor: \u003cem\u003et\u003c/em\u003e = -3.358, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -0.681; K-Interest in words and language: \u003cem\u003et\u003c/em\u003e = -5.368, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -0.961; M- Adapting conversation to others: \u003cem\u003et\u003c/em\u003e = -5.430, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -0.995; N-Building sentences/stories: \u003cem\u003et\u003c/em\u003e = -5.509, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -1.025; and LUI Total score: \u003cem\u003et\u003c/em\u003e = -6.492, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d = -1.124)。Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the comparison of the scores on the 10 subscales and the LUI Total score between the two groups of children (for comparison purposes, the subscale scores were transformed by dividing the actual score by the highest score).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eAssociation between symptom severity and pragmatic ability at follow-up in children with ASD\u003c/h2\u003e \u003cp\u003eThe standardized assessment tools ADOS and ADI-R were used to measure the severity of symptoms in the ASD group at follow-up (n\u0026thinsp;=\u0026thinsp;44), and the P values of the normal K-S test for all symptom dimensions were above 0.05, which was consistent with the normal distribution. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, partial correlation analysis showed that at follow-up, the LUI-Mandarin Total score in the ASD group was significantly negatively correlated with ADOS subscales: ADOS (communicative behaviors) (\u003cem\u003er\u003c/em\u003e = -0.792, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ADOS (social reciprocity) (\u003cem\u003er\u003c/em\u003e = -0.811, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ADOS (play) (\u003cem\u003er\u003c/em\u003e = -0.849, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ADOS (repetitive behaviors) (\u003cem\u003er\u003c/em\u003e = -0.668, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the correlation between the LUI-Mandarin Total score and ADI-R subscales: ADI-R (social) (\u003cem\u003er\u003c/em\u003e = -0.761, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ADI-R (communication) (\u003cem\u003er\u003c/em\u003e = -0.498, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), ADI-R (repetitive behaviors) (\u003cem\u003er\u003c/em\u003e = -0.565, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ADI-R (onset) (\u003cem\u003er\u003c/em\u003e = -0.466, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAssociation between preschool pragmatic ability and baseline levels of GDS and JE in children with ASD\u003c/b\u003e \u003c/p\u003e \u003cp\u003eCorrelation analysis was used to explore the correlation between LUI-Mandarin Total score at follow-up (n\u0026thinsp;=\u0026thinsp;71) and baseline GDS (language behavior) and JE states in children with ASD. Except for GDS (language behavior), the normal K-S test P values of all JE levels were all below 0.05, not in line with the normal distribution. As shown in Figure. 5, Pearson correlation analysis showed that the LUI-Mandarin Total score was significantly positively correlated with baseline GDS (language behavior) (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.555, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Spearman correlation analysis showed that the LUI-Mandarin Total score was significantly negatively correlated with UE (\u003cem\u003er\u003c/em\u003e = -0.295, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012) and positively correlated with SJE (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.591, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but had no significant correlation with OE (\u003cem\u003er\u003c/em\u003e = -0.175, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.145) and CJE (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.222, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.063) at baseline.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRegression analysis of early predictors of preschool pragmatic ability in children with ASD\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows comparison of significant predictors of later pragmatic ability (LUI-Mandarin Total score) under different regression algorithms in the ASD group. The SR-based analysis showed that the R\u003csup\u003e2\u003c/sup\u003e of the model was 0.483, and each factor explained 48.3% of the variation in pragmatic ability. The model passed the F test (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15.387, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000). The factors that had a significant positive impact on pragmatic ability were GDS (language behavior): \u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.553, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.212, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030; SJE: \u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;92.417, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.705, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000; OE: \u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;50.733, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.501, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015. ADOS (social reciprocity) had a significant negative impact on pragmatic ability: \u003cem\u003eB\u003c/em\u003e = -3.531, \u003cem\u003et\u003c/em\u003e = -2.408, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019. The RR-based analysis showed that the model passed the F-test (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.719, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) when K value\u0026thinsp;=\u0026thinsp;0.99 was selected for analysis combined with ridge trace map. The R\u003csup\u003e2\u003c/sup\u003e of the model was 0.503 and each factor explained 50.3% of the variation in pragmatic ability, The adjusted R\u003csup\u003e2\u003c/sup\u003e was 0.318, and the RMSE of the model error was 35.248. The factor that had a significant positive impact on pragmatic ability was GDS (language behavior): \u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.236, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.478, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017; SJE: \u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;24.757, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.556; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001. The factor that had a significant negative impact on pragmatic ability was ADOS (social reciprocity): \u003cem\u003eB\u003c/em\u003e = -1.339, \u003cem\u003et\u003c/em\u003e = -2.162, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.035; and UE: \u003cem\u003eB\u003c/em\u003e = -24.299, \u003cem\u003et\u003c/em\u003e = -2.644, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011. The LR-based analysis method showed that combined with the trajectory map, K value\u0026thinsp;=\u0026thinsp;0.99 was selected for analysis, and the model passed the F test (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.973, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.028). The R\u003csup\u003e2\u003c/sup\u003e of the model was 0.424, each factor can explain 42.4% of the variation in pragmatic ability. The adjusted R\u003csup\u003e2\u003c/sup\u003e was 0.209, and the RMSE of the model error was 37.966. The factors that had a significant positive impact on pragmatic ability included GDS (language behavior): \u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.423, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.122, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000; SJE: \u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;29.178, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.891, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000. ADOS (social reciprocity) had a significant negative impact on pragmatic ability: \u003cem\u003eB\u003c/em\u003e = -2.154, \u003cem\u003et\u003c/em\u003e = -3.229, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002. In addition, analysis based on PLSR showed that the R\u003csup\u003e2\u003c/sup\u003e of the model was 0.566, each factor could explain 56.6% of the variation of pragmatic ability. The RMSE of the model error was 32.96. SJE: \u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;51.532, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.368, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001, indicating that it had a significant positive impact on pragmatic ability. UE: \u003cem\u003eB\u003c/em\u003e = -47.659, \u003cem\u003et\u003c/em\u003e =-2.064, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.043, indicating that it had a significant negative impact on pragmatic ability.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current 3-year longitudinal study examined preschool-age pragmatic ability as assessed via the LUI-Mandarin parent-report measure in children with ASD and TD children and very early predictors thereof. A clinician-rated parent-child play interaction measure was used to assess JE functioning in the ASD group. Regardless of gender and age, TD children tended to exhibit better pragmatic ability than children with ASD, and worse pragmatic ability in children with ASD were correlated with higher levels of autism symptomatology on the ADOS and ADI administered at the preschool-age time point. Moreover, this study extends previous studies documenting long-term associations between JA and subsequent language skills in ASD by demonstrating associations between 24-month JE and pragmatic ability at 5\u0026thinsp;~\u0026thinsp;6 years of age.\u003c/p\u003e \u003cp\u003eMany of the studies exploring pragmatic ability in children with ASD have employed questionnaires to evaluate language use in social contexts. One of the most widely used instruments is the Children\u0026rsquo;s Communication Checklist Second Edition (CCC-2) [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. For example, Baixaiuli-Fortea et al. (2019) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] showed pragmatic impairment in children with ASD aged 7\u0026ndash;11 years as evidenced in difficulties in conversation initiation, context use, non-verbal communication and use of stereotyped language as measured by the CCC-2. Similar findings using the CCC-2 were reported by Kuijper et al. (2017) [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] among children with ASD and TD children aged 6\u0026ndash;12 years. These studies suggest that children with ASD are at elevated likelihood for delays in pragmatic ability by school-age. However, it remains unclear when the delays emerge. Since pragmatic ability have been shown to be important to multiple developmental outcomes [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], identifying early pragmatic language weaknesses might be important for children with ASD to avoid negative outcomes. Our results showed significantly lower scores on all subscales of the LUI-Mandarin, and its Total score, in our preschool-aged ASD group compared with our TD group. Similar results have been reported in a recent study establishing the discriminative validity of LUI-Mandarin [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. In addition, similar findings to ours were reported by Miller et al [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] who used the English LUI to assess early pragmatic ability in siblings of children with ASD compared to TD children. They found that at 36 months, the pragmatic ability of siblings of children with ASD was significantly lower than that of the TD children, and the proportion of children with pragmatic language impairment (PLI; defined as LUI scores falling at or below the 10th percentile) in the sibling with ASD group was significantly higher than that in the TD group (35% vs 10%). These findings indicate that pragmatic difficulties are exhibited early in preschool age, suggesting the need to strengthen early assessment and identification of pragmatic difficulties in children with ASD.\u003c/p\u003e \u003cp\u003eWe explored the associations between pragmatic ability and autism symptomatology as captured by the ADOS and ADI-R in children with ASD. Miller et al also used the LUI to measure pragmatic ability and found significantly higher ADOS scores in their PLI group relative to those without PLI, indicating that children with parent-rated PLI also had greater examiner-rated impairment in social communication [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The consistency between different assessment methods supports the validity of LUI and emphasizes close correlation between the pragmatic ability as per parent report vs directly administered tests. However, restricted, and repetitive behaviors (RRBs) were not examined in Miller et al\u0026rsquo;s study, and so whether those children with PLI also showed higher levels of RRBs remains unknown [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Ray-Subramanian et al. (2012) [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e] however, did find that expressive and receptive language were significantly negatively correlated with RRBs in children with ASD at 3 years of age. Notably, our study found that, in addition to expressive and receptive language, a significant negative correlation was found between pragmatic ability and RRBs in preschool children with ASD, contributing a new finding to previous studies. Future research is needed to understand the relationship between pragmatic language and RRBs as well as the underlying mechanism.\u003c/p\u003e \u003cp\u003eAn important finding of the present study was that the proportion of SJE in early parent-child interaction is closely related to later pragmatic ability, and regression analysis also confirmed that, regardless of the algorithms, SJE was the most valuable predictor of future pragmatic ability in children with ASD. Consistent with our finding, Adamson et al. [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] showed that language outcomes of children with ASD were related to the frequency of SJE, but not closely related to CJE. The language outcomes they discussed were in the category of structural language, whereas our study focused on the pragmatic language outcome of children with ASD. A study by Shih et al. (2021) [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] investigated the mediating effect of SJE on the effect of IJA intervention, and the importance of IJA on expressive and receptive language in children with ASD. They found that SJE significantly mediated 69% of the effect of IJA intervention, and IJA was a predictor of later expressive and receptive language skills. These findings suggest that increasing the proportion of SJE during parent-child interaction is a potential intervention for IJA improvement, that could also further improve the language skills in children with ASD. However, more research is needed to further explore the relationship between early SJE skills, IJA skills and later pragmatic ability in children with ASD.\u003c/p\u003e \u003cp\u003eIn addition, our correlation and regression analyses also showed that early structural language ability was an important factor affecting later pragmatic language outcomes in children with ASD. Matthews et al. (2018) [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e] reviewed research regarding the association between pragmatic ability and three important factors including structural language, theory of mind and executive function in children with typical and atypical development, and found that the correlation between pragmatic language and structural language was the most consistent. Similarly, a review by Boucher (2012) [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e] also showed that pragmatic language outcomes were most affected by the structural language in children with ASD. In addition, previous studies have shown that structural language are intertwined with pragmatic language (including metaphor comprehension [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], idiomatic language [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], and context disambiguation [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Studies have also shown that improving structural language can benefit children with ASD with pragmatic difficulties [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of this study\u003c/h2\u003e \u003cp\u003eThe present study has several strengths, including the focus on both maternal and child characteristics at baseline as well as the analysis of video-recorded parent-child interactions and the use of multiple regression algorithms providing different advantages. However, this study also has several limitations. First, pragmatic language and structural language abilities are intertwined rather than fully distinct and autonomous systems, so it\u0026rsquo;s hard to really separate them. Second, although parent-report measures enable a more comprehensive assessment of a young child\u0026rsquo;s pragmatic language competence, a full picture of a child\u0026rsquo;s pragmatic language requires multiple types of assessments [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e], future research could additionally assess children\u0026rsquo;s pragmatic abilities in natural contexts where these skills can be directly observed in real time [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Third, at follow-up only a smaller subset of the enrolled children with ASD underwent clinical diagnosis and were administered the standardized ADOS and ADI-R assessments. This smaller sample size limits the generalizability of results examining the association between levels of autistic symptomatology and pragmatic ability.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe present study provides evidence of pragmatic language difficulties in preschool children with ASD and, moreover, a gradient effect in that the greater the difficulties in pragmatic ability, the greater the severity of autistic symptoms. Further, results indicated that early SJE and structural language were important predictors of later pragmatic ability. We suggest as a result that early intervention targeting these abilities may be critical for promoting successful pragmatic communication outcomes for children with ASD.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Nanjing Brain Hospital affiliated with the Nanjing Medical University Ethics Committee, participants were consented by an informed consent process that was reviewed by the Ethics Committee of Nanjing Medical University and certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki, and informed consent was obtained from the parents or legal guardians of the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors (Lu Qian, Ning Ding, Hui Fang, Ting Xiao, Bei Sun, HuiYun Gao, XiaoYan Ke) declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported\u0026nbsp;by the National Key Research and Development Program of China\u0026nbsp;(2016YFC1306200), the National Natural Science Foundation of China (81771478) and the \u0026ldquo;Special disease cohort\u0026rdquo; Research Project of Nanjing Medical University (NMUC2018010A).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceived and designed the research: X-y K. Wrote the paper: LQ. Collected the data: ND, HF, TX, BS, H-y G. Analyzed the data: LQ. Revised the paper: X\u0026ndash;y K and LQ. The authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are thankful for the support of the fundings, and acknowledge the participants and their families for their support, as they made this study possible. We also extend thanks to Dr. Daniela K. O\u0026rsquo;Neill, who provided guidance and advice on the draft and revised the draft.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). Washington, DC: American Psychiatric Pub; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaste P, Leboyer M. Autism risk factors: genes, environment, and gene-environment interactions. 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J Autism Dev Disord. 2009;39(1):115\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Marchena A, Eigsti IM. The art of common ground: emergence of a complex pragmatic language skill in adolescents with autism spectrum disorders. J Child Lang. 2016;43(1):43\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKetelaars MP, Cuperus J, Jansonius K, Verhoeven L. Pragmatic language impairment and associated behavioural problems. Int J Lang Comm Dis. 2010;45(2):204\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCummings L. Boy aged 4;8 years with specific language impairment. Case Stud Comm Dis. 2016;12:85\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaws G, Bates G, Feuerstein M, Mason-Apps E, White C. 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Child Dev. 1984;55(4):1278\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdamson LB, Bakeman R, Suma K, Robins DL. An Expanded View of Joint Attention: Skill, Engagement, and Language in Typical Development and Autism. Child Dev. 2019;90(1):e1\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKasari C, Freeman S, Paparella T. Joint attention, and symbolic play in young children with autism: a randomized controlled intervention study. J Child Psychol Psyc. 2006;47(6):611\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdamson LB, Bakeman R, Deckner DF. The development of symbol-infused joint engagement. Child Dev. 2004;75(4):1171\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdamson LB, Bakeman R, Deckner DF, Romski MA. Joint engagement and the emergence of language in children with autism and down syndrome. 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Autism. 2013;17(5):558\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Vaughan A, Mundy PC, Acra CF, Block JJ, Delgado CE, Parlade MV, et al. Infant joint attention, temperament, and social competence in preschool children. Child Dev. 2007;78(1):53\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBall RS. The gesell developmental schedules: arnold gesell (1880\u0026ndash;1961). J Abnorm Child Psych. 1977;5:233\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLord C, Rutter M, Goode S, Heemsbergen J, Jordan H, Mawhood L. Autism diagnostic observation schedule: a standardized observation of communicative and social behavior. J Autism Dev Disord. 1989;19(2):185\u0026ndash;212.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLord C, Rutter M, Le Couteur A. 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Defining spoken language benchmarks and selecting measures of expressive language development for young children with autism. J Speech Lang Hear R. 2009;52:643\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHyter YD. A conceptual framework for responsive global engagement in communication sciences and disorders. Top Lang Disord. 2014;34(2):103\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"autism spectrum disorder, pragmatics, predictors, supported joint engagement","lastPublishedDoi":"10.21203/rs.3.rs-4703774/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4703774/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePragmatic language refers to the use of spoken language to effectively convey messages across diverse social communication contexts. However, minimal longitudinal research has focused on defining early predictors of pragmatic development in children with autism spectrum disorder (ASD).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn the current study, 71 ASD and 38 age- and gender- matched 24- to 30-month-old typically developing (TD) children were enrolled. Social-communication, language, and parent-child interaction measures were collected for the ASD group at baseline. Three years later, all subjects were assessed for pragmatic ability via the Chinese version of Language Use Inventory (LUI-Mandarin). First, the differences of pragmatic performance between the ASD group and the TD group at follow-up were analyzed. Second, pragmatic performance was correlated with autism symptomatology at follow-up, as well as the structural language difficulties and joint engagement (JE) levels at baseline for the ASD group. Furthermore, diverse multiple regression algorithms were performed to explore the effect of the early potential predictors of pragmatic development for the ASD group.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFirst, our results revealed that performance was significantly lower in the ASD group than in the TD group with respect to LUI-Mandarin Total scores and subscale scores (\u003cem\u003et =\u003c/em\u003e -3.358 ~ -6.870, \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;0.05). Second, correlation analysis showed that more severe symptoms of ASD at follow-up were associated with lower LUI-Mandarin Total scores (\u003cem\u003er\u003c/em\u003e = -0.489 ~ -0.853, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and better language performance of Gesell (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.555, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In addition, increased proportions of supported JE(SJE) state (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.591, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were associated with higher LUI-Mandarin Total scores, while increased proportions of unengaged (UE) state were associated with lower LUI-Mandarin Total scores (\u003cem\u003er\u003c/em\u003e = -0.295, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) for the ASD group. Third, diverse multiple regression algorithms consistently indicated that the proportions of SJE during parent-child interactions was a significant contributor to pragmatic development for the ASD group in the prediction models.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn summary, our findings suggest that pragmatic language difficulties are present in children with ASD as early as preschool age. Additionally, given the close correlation between the LUI-Mandarin and symptom severity on ADOS/ADI-R, the LUI-Mandarin might be a good way to triage children who need to wait a long time for a more extensive evaluation. Furthermore, more time occupied in SJE could be an important predictor for better pragmatic language outcomes for children with ASD.\u003c/p\u003e","manuscriptTitle":"Pragmatics performance, the relation to symptom severity, and early clinical predictors of pragmatics in 5~6-year-old children with autism spectrum disorder","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 21:09:16","doi":"10.21203/rs.3.rs-4703774/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-11T15:57:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-10T17:27:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-09T11:38:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248796516845825237200951917005856960483","date":"2024-10-07T12:30:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44518102452962445007131803526302576553","date":"2024-09-30T12:08:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-22T13:09:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-11T21:51:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-10T04:58:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-10T04:57:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-07-08T08:14:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"16906bf5-55df-4a3e-ba2b-f985e6f1b8db","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T16:00:22+00:00","versionOfRecord":{"articleIdentity":"rs-4703774","link":"https://doi.org/10.1186/s12888-024-06452-1","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2025-01-20 15:57:15","publishedOnDateReadable":"January 20th, 2025"},"versionCreatedAt":"2024-08-09 21:09:16","video":"","vorDoi":"10.1186/s12888-024-06452-1","vorDoiUrl":"https://doi.org/10.1186/s12888-024-06452-1","workflowStages":[]},"version":"v1","identity":"rs-4703774","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4703774","identity":"rs-4703774","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}