Introduction

Traditionally, pragmatics refers to the use of language to convey meaning in a particular context and culture1,2. More recently, a multimodal perspective has been adopted in explaining pragmatics, including not only linguistic communication but also other nonverbal means of expression, namely extralinguistic and paralinguistic, which play a crucial role in communication3,4. Non-verbal/extralinguistic means include all communication activities that occur through the use of gestures and facial expressions, while paralinguistic means refer to communicative exchanges that occur through prosody and tone of voice3,5.

Regardless of the means of expression used, pragmatics provides access to the intended meaning of a communicative act when it differs from the literal meaning, as is the case with indirect speech acts, irony, metaphors, and other forms of figurative language. Pragmatics plays a fundamental role in everyday social communication, both in comprehension and production, and enables appropriate and effective conversation6.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5;7), introduced Social Pragmatic Communication Disorder (SPCD), which is characterised by difficulties in pragmatic ability. According to the DSM-5, individuals with SPCD may exhibit deficits in the following skills: (1) using social communication for specific purposes; (2) modifying and adapting language to context and interlocutor; (3) being effective and following communication rules in conversations and/or storytelling; (4) understanding implicit meanings and figurative language7.

Differently, the ICD-11 Manual8 does not contain the term SPCD and categorizes children with pragmatic difficulties under the term “Developmental language disorder with impairment of mainly pragmatic language”. In the DSM-5, this disorder is also categorized as “neurodevelopmental disorders”, but within the subcategories of “developmental speech and language disorder” and “developmental language disorder”.

Before 2013 not clear boundary existed, in the differential diagnosis, between impairments in the in social interaction and pragmatics communication. According to the DSM IV9, children with difficulties in pragmatics who did not meet the criteria for Autism Disorder, a neurodevelopmental condition characterised by deficits in social communication and interactions, and by the presence of repetitive, stereotyped, restricted behaviours and interests, could be grouped under the category of Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). In addition to this diagnosis included in the manual, several authors and clinicians used to refer to the term Pragmatic Language Impairment (PLI) to identify this population (e.g10,11,12). PLI was also previously referred to as “semantic-pragmatic disorder” and was used to describe children’s difficulties in conversational tasks, such as socially inappropriate production13,14. In a recent review15 on PLI, differences in the terminology used to describe pragmatic disorders were noted, with various terms used interchangeably by researchers as synonyms, albeit with some inconsistencies. Moreover, Alduais and colleagues15 pointed out differences in the various frameworks proposed to describe this disorder. In the fifth edition of the DSM, some changes were made to these categories as well, most notably adding the term Autism Spectrum Disorder (ASD) to identify the former macro-category of Pervasive Developmental Disorders (Autism Disorder, Asperger’s Disorder, Rett’s Disorder, Childhood Disintegrative Disorder and PDD-NOS). However, with the new criteria, some children previously diagnosed with one of the subcategories of PDD according to DSM-IV may meet DSM-5 criteria for SPCD16.

When analysing the differential diagnosis between SPCD and ASD, it can be noted that their main difference relies upon the presence of repetitive behaviours in the population of children with ASD7. Moreover, SPCD diagnosis has several overlaps also with Developmental Language Disorder (DLD), which is characterised by impairment in at least one language domain, namely phonology, semantics, morphology, syntax, and pragmatics. DLD is a fairly new term that the CATALISE consortium agreed to adopt in 2017 thanks to a Delphi consensus17. The DSM-5 does not mention this term, instead using the term “Language Disorders” to identify children with difficulties in the development and use of language in both production and comprehension. Another term used in clinical and research settings to identify children and adolescents with language disorders is Specific Language Impairment (SLI)17, although it is not included in any diagnostic manual. Although there is no consensus on this topic, some authors have hypothesised that PLI may represent a subset of SLI18.

The similarities in the main features of the above-mentioned disorders, i.e., SPCD, ASD, or DLD, and the existing confusion about the terminology used to identify these clinical conditions have contributed to the development of a debate in the scientific community, about the challenges of establishing an accurate differential diagnosis. Indeed, a number of authors have discussed the validity of SPCD criteria and their strengths and limitations in making differential diagnoses between the above clinical categories19,20,21. Some authors suggested that SPCD may lie on a continuum between DLD and ASD20,22 while others, more in line with the structure present in the DSM-5, support the existence of a specific clinical population that meets SPCD criteria23,24; finally, Redmond25 suggests that SPCD may be considered a transdiagnostic symptom cluster rather than a specific diagnostic entity.

These uncertainties have led to an increasing interest in examining the correspondence between the new diagnostic categories introduced by the DSM-5 and their recognition in clinical populations. However, a decade has passed since the publication of the DSM-5, and only few empirical studies have been conducted in this area. For example, a recent review26 identified 18 studies on SPCD published between 2013 and 2023, highlighting that only six of them were conducted in the context of ad hoc studies and newly collected data, while the others relied upon the analysis of data previously collected for other scopes. In addition, some authors27,28 emphasised the lack of a specific assessment tool to be labelled as a golden standard for the sensitivity in accurately detecting specific pragmatic difficulties in children with SPCD, taking into account all the domains encompassed in the functioning profile of the disorder, as described in the DSM-5.

Furthermore, numerous cognitive abilities (e.g., Executive Functions and Theory of Mind) interact with pragmatics. Executive Functions (EFs) refer to the ability to control goal-directed behaviours in an adaptive and flexible manner29 while Theory of Mind (ToM) is defined as the ability to infer the mental states of others30. However, the exact relationship between these cognitive abilities and pragmatics is not yet completely clear31,32,33,34,35,36. Moreover, the close relationship with the context in which communicative acts take place, the different difficulty of comprehension of various communicative acts – such as direct and indirect speech acts, irony, metaphors, etc. - and the existence of various means of expression, contribute to the difficulties in developing comprehensive standardised assessment instruments.

Given the importance of communicative ability in interacting with other people, it is easy to understand how SPCD can affect various activities of daily living and why children with SPCD diagnosis may have negative outcomes in several aspects of their life. In particular, pragmatic deficits could be related to social-emotional and behavioural problems, as well as difficulties with school readiness37,38. This is not unexpected given the extent to which pragmatics is involved in academic skills (e.g., in text comprehension, when it is necessary to infer some implicit meanings), in social interactions (e.g., in following some conversational rules such as turn-taking or politeness), and in its interaction with EFs and ToM39. In particular, persistent difficulties in social communication may lead to poorer peer relationships40.

Most of the above difficulties are sometimes observed also in children who fall into the Italian category “Bisogni Educativi Speciali” (BES), introduced by a ministerial directive issued by the Italian Ministry of Education, University and Research (MIUR) on December 27, 201241. This Italian term denotes a category similar to the one identified by the term “Special Educational Needs” (SEN) introduced in the United Kingdom in 1978 by the Warnock Report42. Although it is not a nosographic classification, the category BES includes children with a wide range of permanent or temporary difficulties in school activities due to physical, biological, physiological, psychological or social reasons (Italian Ministerial Directive, December 27, 2012)41. This directive and the following Italian Ministerial Circular (No. 8, March 6, 2013)43 distinguish three different subcategories of BES: (1) children with certified disabilities, as Attention Deficit Hyperactivity Disorder (ADHD), (2) children with specific developmental disorders, such as Specific Learning Disorder (SLD); (3) children with other, not otherwise specified, Special Educational Needs (BES-NOS). SLD is a neurodevelopmental disorder characterised by difficulties in one or more of the following skills: spelling, reading, writing (orthography and/or handwriting), and mathematics7. Recent studies have highlighted the presence of pragmatic difficulties, particularly in understanding figurative language, i.e., metaphors and proverbs, in children and adults with SLD as well44,45,46,47. In the present paper we will focus on children with BES belonging to this third, under investigated subcategory, i.e. BES-NOS, exploring the presence of specific communicative-pragmatic difficulty.

Due to its educational nature, the designation BES is not necessarily the result of a medical diagnosis, except for the special situations described in subcategories 1 and 2. With the Italian Ministerial Directive of 2012, indeed, inclusive education was extended to a larger number of children with permanent or temporary difficulties, taking into account not only the presence of manifest pathologies, but the biopsychosocial perspective according to the International Classification of Functioning (ICF)48.

Unlike other countries, e.g. the United Kingdom, Italian schools do not have health and education professionals, such as Speech and Language Therapists (SLTs), provided by the school system. In fact, SLTs in Italy do not work in schools but only in health facilities or in private practises. Access to these services is only through a medical prescription; for this reason, most families turn to these services because of serious difficulties or on the advice of the teachers, who do not always have appropriate tools and clinical sensitivity to identify the variety of potential difficulties. This difference could be crucial in identifying children with social communication problems and it requires greater interaction between the school and the health systems.

In recent years, few studies have examined the academic skills of children with SPCD37,38,49. All three studies used the Children Communication Checklist, Second Edition (CCC-2)50 to identify children with pragmatic difficulties who may be classified as SPCD; in addition, Freed and colleagues (2011) also combined the Social Communication Behaviour Checklist (SCBC) to this measure. All of these studies included the examination of nonverbal cognitive skills. Freed and colleagues49 found that children with SPCD have high levels of literacy difficulties, and in their subsequent study37, they emphasised that spoken above-sentence level comprehension (ASLC) can predict reading comprehension skills in children with SPCD. Similarly, Saul et al.38 find that children with SPCD often exhibit academic difficulties, but their study shows no prediction of academic achievement by pragmatic ability, after controlling for structural language.

To date, to our knowledge, there are no studies aimed at distinguishing children with SPCD from those with SEN in the international literature and for the Italian population in the category BES-NOS. As in the international community, there is a paucity of assessment tools for assessing pragmatic skills along development in Italy. However, some instruments are available on the market, such as the Italian version of the “Children Communication Checklist, Second Edition” (CCC-2)50, “Abilità Pragmatiche nel Linguaggio” Medea (APL Medea)51 and the “Assessment Battery for Communication” (ABaCo)52,53 adapted for children54. ABaCo is composed by fives scales, linguistic, nonverbal/extralinguistic, paralinguistic, contextual and conversational, each investigating a specific expressive means or pragmatic aspect. ABaCo is a validated, comprehensive assessment tool for pragmatic comprehension and production, also available in two equivalent forms55 enabling test/re-test procedures. Previous studies have used this battery to investigate a wide range of pragmatic phenomena in various populations, including the elderly56, people with schizophrenia57, and acquired brain lesions58,59,60. In addition, the adapted version for children is also available and has been used to assess pragmatic ability in typical54 and atypical development, in particular with autistic children61 and adolescents62 as well as children with cochlear implants63. Finally, ABaCo has been partially cross-culturally translated and adapted in different languages, e.g., English64, Serbian65, Finnish66 and Portuguese67.

The present study

The purpose of this study is to investigate the pragmatic performance of children with BES not otherwise specified (BES-NOS) and to compare it with the performance of children with typical development. Children of other subcategories of BES (i.e. certified disabilities such as ADHD and SLD) were excluded from the present study because these disorders have a primary cognitive difficulty (i.e. attentional deficit or language deficit) directly influencing their pragmatic performance.

We expected children with BES-NOS have a worse communicative pragmatic performance on ABaCo than typically developing children. In addition, we explored the possibility to identify a subgroup of children with undiagnosed SPCD among children with BES-NOS.

Methods

Participants

Sixteen children and adolescents (7 females) with BES-NOS, aged 7 to 16 years, and 16 children and adolescents with Typical Development (TD) (6 females) participated in the study. The participants with BES-NOS were recruited via collaboration with “AnimaLaMente – servizi per il benessere psicofisico” in Seregno (MB), Italy, an Italian centre for screening for SLD, while the TD participants were recruited through the research group’s social media (Facebook, Instagram, Twitter, etc.) and personal contacts. Inclusion criteria for all participants were the following: Italian native speakers, intelligence quotient (IQ) above 80 and basic linguistic skills in both comprehension and production. The latter criteria were verified, respectively, via the Raven’s Standard Progressive Matrices68, with reference to the Italian standardized norms for children69, that allows a conversion of the raw scores in standardized IQ values, through the Publisher’s website (Giunti Psychometrics) and the subtest of the Comprehension of instruction and verbal fluency of the validated battery NEPSY-II70, Italian standardization71.

All children in the BES-NOS group had also received a comprehensive learning skills assessment by the screening centre to rule out any undetected diagnosis of SLD. After the first data preprocessing, two children initially recruited for the BES-NOS group were excluded from the study because they did not meet the inclusion/exclusion criteria. Therefore, 14 children with BES-NOS (7 girls and 7 boys) took part in the study. The age range was 7 to 15 years (M = 10.93; SD = 2.30), whereas the IQ ranged from 83 to 118 (M = 98.50; SD = 9.47). The age range of the control group was from 9 to 14 years (M = 10.71; SD = 1.44) while the IQ ranged from 81 to 121 (M = 98.50; SD = 15.77). The Mann-Whitney U test revealed that the two groups did not differ in terms of age (U = 98.00; z = 0.00; p = 1.000, r = .00), IQ (U = 89.50; z = − 0.392; p = .701, r = .074), Education (U = 98.00; z = 0.866; p = .571; r = .163) and Sex (U = 98.00; z = 0.00; p = 1.000; r = .00).

For both the BES-NOS and the TD groups, we asked parents to complete a questionnaire to collect information on the family composition, educational level, and parents’ occupation, in order to determine their Social Economic Condition (SEC). Specifically, we used the Four-Factor Index of Social Status72 (see Supplementary Material), with categories based on the Italian social context (ISTAT 2021)73. Families SEC scores are calculated by multiplying both parents scale scores for occupation and education, by factor weights of 7 and 4, respectively, to obtain the sum of these factors. If only one parent is employed, only this index is used; otherwise, the mean of the parents’ indices is considered.

For the BES-NOS group, this index ranged from 18.5 to 66 (M = 43.71, SD = 12.83); for the TD group, it ranged from 22 to 58 (M = 41.07; SD = 11.90). We run Mann Whitney U test to verify that the two groups did not differ on the SEC index (U = 85.50; z = − 0.577, p = .571, r = − .109).

The demographic characteristics of the two groups are reported in Table 1.

Table 1 Characteristics of the two groups (BES-NOS) and the controls in terms of age, sex IQ and SEC (Index of Social Position; ISP).
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Materials and procedure

Assessment Battery for Communication (ABaCo)52,53, child version54: it is a validated and pre-tested assessment tool that consists of 172 items that include vis-à-vis interactions and short videos on various communicative phenomena. The battery is composed of five scales, i.e., linguistic, extralinguistic, paralinguistic, contextual, and conversational, and focuses on a wide range of communicative acts e.g., direct and indirect communicative act, irony and deceit. Each scale tests pragmatic skills in both comprehension and production, with the exception of the conversation scale, where these two processes are considered together. This assessment tool provides information about the participants’ global pragmatic performance (ABaCo total score) and their performance on each single scale (linguistic, extralinguistic, paralinguistic, contextual and conversational). ABaCo responses are coded 0 (wrong) or 1 (correct answer) offline, based on the sessions’ video-recordings. Some examples of the pragmatic phenomena assessed in each ABaCo scale can be found in Table 2.

Table 2 Examples of tasks and phenomena assessed in ABaCo scales.
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NEPSY-II Battery70,71, comprehension of instruction and verbal fluency subtests. The comprehension of instruction subtest aims to examine children’s ability to elaborate and execute verbal instructions characterized by progressive syntactic complexity. The responses are coded with the score 1 if the children identify the correct target and 0 for a wrong answer, identification of the correct items but in the wrong sequence or in the absence of a response. The verbal fluency subtest assesses the child’s ability to access and recall a specific lexicon and to quickly form words that correspond to a specific semantic or phonological category in 60 s.

The Four-Factor Index of Social Status72 is a questionnaire designed to examine social and economic status, and widely used in international and Italian contexts (e.g.33,54,74,75), to collect information on family composition, parents’ occupation, and educational attainment.

Participants who met the inclusion criteria were identified and contacted to present the objectives and design of the study. Only participants whose parents (both) provided written informed consent were included in the initial screening. All methods and procedures were performed in accordance with the Declaration of Helsinki and the project was approved by the Bio-Ethical Committee, University of Turin, protocol n. 195873.

The assessment material was administered in two individual sessions, each lasting approximately one and a half hours and held in a quiet location, with breaks taken as needed to rule out an effect due to fatigue. All sessions were video recorded to allow offline scoring by independent evaluators.

Data analysis

The distributions of the scores of the two groups on the ABaCo total score, were not normal based on both Kolmogorov-Smirnov’s tests (p < .006) and Shapiro-Wilk tests (p < .001). Thus, first of all, in order to meet the assumptions required by parametric analyses, we performed an arcsine transformation of children’s performance on ABaCo.

In order to examine potential differences in pragmatic ability between groups, based on the ABaCo total score, we thus performed an independent sample t-test (two-tailed, with alpha set as 0.05). Then, to compare the performance of the two groups on each scale of the ABaCo we conducted repeated-measures ANOVA with a between-subjects factor (type of group, with two levels) and a within-subjects factor (ABaCo scales, with five levels: linguistic, paralinguistic, extralinguistic, contextual, and conversational).

In line with other studies60,76, in order to investigate the possible existence of a subgroup of BES-NOS with a specific impairment in pragmatic ability, we carried out hierarchical Cluster Analysis using Ward’s method, which minimises the total within-cluster distance, by using the ABaCo total score.

Finally, in order to verify the absence of differences in terms of age, IQ and SEC between the identified subgroups of participants, we performed a non-parametric Mann-Whitney U test, as these specific participants’ data, for their nature and the aims of this paper, did not require any normalization with respect to age, IQ, and SEC.

Results

To analyse participants’ performance on the ABaCo total score, we performed an independent-samples t-test. As expected, there was a significant statistical difference between the two groups for the global ABaCo score, with the BES-NOS group performing worse than the TD group (t₍₂₆₎ = 2.320; p = .028; Cohen’s d = 0.877).

To analyse subjects’ performance on each ABaCo scale, we conducted a repeated-measures ANOVA, with a between-subjects factor (type of group, with two levels: BES-NOS and TD) and a within-subjects factor (ABaCo scale, with five levels: linguistic, paralinguistic, extralinguistic, contextual, and conversational). Repeated-measures ANOVA showed an effect of group type, F₍4,104₎ = 13.084; p ≤ .001; ƞp² = 0.335) with BES-NOS performing worse than TD, and an effect of scale type (F₍1‚26₎ = 6.344; p = .018; ƞp² = 0.196). Pairwise comparisons revealed a statistically significant difference between the performance of BES-NOS and the TD group in the linguistic (p = .045), paralinguistic (p = .007), and conversational scales (p = .040), but not in the other two scales of ABaCo, i.e., the extralinguistic scale (p = .204) and the contextual scale (p = .434). The performance scores of the BES-NOS and TD groups in each of the ABaCo scales and on total score are summarised in Fig. 1.

Fig. 1
Fig. 1
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Performance scores of the BES-NOS and TD groups on ABaCo scales (linguistic, paralinguistic, extralinguistic, contextual, and conversational) and ABaCo total score.

To investigate whether it was possible to find a subgroup of children with BES-NOS with greater difficulties in the area of pragmatic skills, we performed a hierarchical Cluster Analysis including the group BES-NOS only, and using Ward’s method, which minimises the total distance within-cluster, using the ABaCo total score (Fig. 2).

Fig. 2
Fig. 2
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Hierarchical cluster analysis of the all BES-NOS group using the ABaCo total score.

The cluster analysis identified 2 groups of children: Cluster 1, consisting of 8 children (2 girls, 6 boys) and Cluster 2, consisting of 6 children (4 girls, 2 boys). Looking at the mean scores of the clusters on the ABaCo total score, we can observe lower performance scores of the first cluster compared to the other (Table 3). To clarify this, from now on we will refer to Cluster 1 as BES-NOS with Specific Pragmatic Difficulty (BES-NOS-PD) and Cluster 2 only with the acronym BES-NOS-noPD, which stands for “no Pragmatic Disorder”. In order to verify that the children belonging to the two identified clusters (BES-NOS-PD and BES-NOS-noPD) did not differ in terms of age, IQ and SEC, on which the detected differences might rely, we performed a series of comparisons using Mann-Whitney U test. The results showed not significant difference between the children in these two clusters in terms of age (U = 31.00; z = 0.906; p = .414, r = .171), IQ (U = 31.00; z = 0.911, p = .414, r = .172), nor SEC (U = 27.50; z = 0.463, p = .414, r = .087).

Table 3 Performance scores on ABaCo total score of the BES-NOS group (overall and divided in BES-NOS-PD and BES-NOS-noPD) and of the TD group.
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The independent-samples t-test revealed a significant statistical difference between the two clusters for the ABaCo total score, with the BES-NOS-PD cluster performing worse than the BES-NOS-noPD cluster (t₍12₎ = 7.771; p ≤ .001; Cohen’s d = 0.164).

To better understand the extent to which the differences between the BES-NOS-PD cluster and the BES-NOS-noPD cluster may have affected the differences in pragmatic performance between the BES-NOS group and the TD group, we performed a second Hierarchical Cluster Analysis, including all participants (BES-NOS-PD, BES-NOS-noPD and TD children - Fig. 3).

Fig. 3
Fig. 3
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Hierarchical cluster analysis of all study participants (BES-NOS-PD, BES-NOS-noPD and TD) for ABaCo total score.

This second Hierarchical Cluster Analysis using Ward’s method identified two clusters: one cluster consisted of 19 subjects (10 females; 9 males); the other Cluster consisted of 9 subjects (2 females, 7 males). Based on this analysis, the first cluster included the children of the TD group and those of the cluster BES-NOS-noPD. Cluster 2, instead, included 9 children corresponding to the previously formed cluster BES-NOS-PD, derived from the previously cluster analysis, with the addition of a control subject who probably acted as an outlier. Again, looking at the mean scores of the clusters on the ABaCo total score, we can observe a worse performance of the cluster BES-NOS-PD compared to the other (BES-NOS-noPD + TD).

We then performed an independent-samples t-test for the ABaCo total score to further examine the differences between the two clusters identified. The analysis showed a statistically significant difference, with the BES-NOS-PD Cluster performing worse than the cluster consisting of the BES-NOS-noPD + TD (t(26) = 5.979; p ≤ .001; Cohen’s d = 2.501).

Finally, to analyse subjects’ performance on each ABaCo scale, we performed a repeated-measures ANOVA with a between-subjects factor (type of group, with two levels: Cluster BES-NOS-PD; Cluster BES-NOS-noPD + TD) and a within-subjects factor (ABaCo scale, with five levels: linguistic, paralinguistic, extralinguistic, contextual, and conversational). Repeated-measures ANOVA showed an effect of group type (F₍4,104₎ = 9.287; p ≤ .001; ƞp² = 0.263), with BES-NOS-PD performing worse than the other group, and an effect of scale type, F₍1‚26₎ = 2.128; p ≤ .001; ƞp² = 0.658). Pairwise comparisons revealed a statistically significant difference between the performance of BES-NOS-PD and the other group (BES-NOS-noPD + TD) on the extralinguistic (p = .002), the paralinguistic (p ≤ .001), the conversational scale (p = .002), and the contextual scale (p ≤ .001). The differences in performance on the linguistic scale are just above the threshold for statistical significance (p = .054). The scores achieved by participants in the two groups on each ABaCo scales and on ABaCo total score are reported in Fig. 4.

Fig. 4
Fig. 4
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Performance of the cluster BES-NOS-PD and the cluster consisting of the TD and BES-NOS-noPD on ABaCo scales (linguistic, extralinguistic, paralinguistic, contextual, and conversational) and on the ABaCo total score.

Again, we compared these two new clusters of participants (BES-NOS-PD vs. BES-NOS-noPD + TD) using the Mann-Whitney U test to verify that the new identified subgroups do not differ in terms of age (U = 96.00; z = 0.814, p = .438, r = .154), IQ (U = 101.00; z = 0.766, p = .468, r = .145), and SEC (U = 77.50; z = − 0.128, p = .566, r = .024), since these variables might have affected the observed previous results showing a significant difference in their pragmatic performance.

The results of the second cluster analysis, combined with those of ANOVA, lead us to doubt that the results observed in the first analysis (BES-NOS vs. TD) were only due to the weaker performance of the subgroup of BES-NOS with pragmatic difficulty (BES-NOS-PD). Thus, to investigate this possibility, we conducted supplementary analyses to determine whether there were statistically significant differences between the performance of children with BES-NOS without PD and TD. The independent-samples t-test on the ABaCo total score confirmed that there was not significant statistical difference between the two groups (t₍18₎ = 0.608; p = .551; Cohen’s d = 0.297).

We then conducted a repeated-measures ANOVA with a between-subjects factor (type of group, with two levels: BES-NOS-noPD and TD) and a within-subjects factor (ABaCo scale, with five levels: linguistic, paralinguistic, extralinguistic, contextual, and conversational). The ANOVA did not show an effect of group type (F₍1‚18₎ = 0.444; p = .514; ƞp² = 0.024), whereas it detected an effect of scale type (F₍4,72₎ = 7.556; p ≤ .001; ƞp² = 0.296). Pairwise comparisons revealed the absence of a statistically significant difference between the performance of BES-NOS-noPD and the control group (TD) in the linguistic (p = .360), extralinguistic (p = .404), paralinguistic (p = .898), contextual (p = .120), and conversational scales (p = .857). The performance of the BES-NOS-noPD and TD groups in the individual ABaCo scales and in the total score are summarised in Fig. 5.

Fig. 5
Fig. 5
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Performance scores of the BES-NOS-noPD and TD groups on ABaCo scales and on the ABaCo total score (linguistic, extralinguistic, paralinguistic, contextual, and conversational).

Discussion

The aim of the study was to identify potential pragmatic difficulties in children and adolescents with BES-NOS, a term we use to refer specifically to children with BES (Italian label for special needs) but without certified disorders such as DLD, SLD, and ADHD or disabilities (e.g., intellectual disability). For this purpose, the pragmatic performance of the group of children with BES-NOS was compared to that of a control group. Children in the clinical group underwent a comprehensive examination to rule out the presence of SLD and others among the above-mentioned diagnosis. In addition, all the participants were administered language and cognitive tasks using NEPSY-II language subtests70 and Raven Progressive Matrices68, in order to verify linguistic and cognitive skills within the normative range for their age. Finally, SEC and anamnestic information were collected for all participants.

The fulfillment of this first aim represented the base for a second goal of the present paper, i.e., to explore the possibility to identify a subgroup of children with undiagnosed SPCD among children with BES-NOS. To date, no consensus has been reached on a gold standard assessment tool to identify SPCD26,27,28. Specifically, in the DSM-57, SPCD is characterized by difficulties in using verbal and nonverbal communication for social purposes, which may affect both communicative comprehension and production within social interaction. In particular, the DSM-5 describes four areas of impairment for SPCD: (1) using communication for social purposes appropriately according to the social context; (2) adapting communication to the context; (3) following rules for conversation and storytelling; (4) drawing inferences and understanding non-literal language. For this study, we used the child adaptation of ABaCo52,54, which provides a comprehensive assessment of pragmatic ability, including an examination of all of these domains.

The preliminary results of this study seem to suggest that ABaCo could be an effective assessment tool to identify pragmatic difficulties in children and adolescents across domains. Indeed, the ABaCo total score showed a statistically significant difference between BES-NOS and the control group (TD). These results support our experimental hypothesis that the BES-NOS group performed worse than the TD group. It is worth noting that we excluded from the BES-NOS group all children with BES specific diagnoses, such as ADHD or SLD, because their specific diagnosis could affect their pragmatic performance.

Looking at performance on the individual scales of the ABaCo, the results showed a statistically significant difference between the two groups on the linguistic, paralinguistic, and contextual scales, but not on the extralinguistic and conversational scales. In line with the methodology adopted by other authors, we investigated for exploratory purposes, whether it was possible to identify children with pragmatic difficulties in the BES-NOS group.

We therefore conducted a Cluster Analysis that allowed us to identify two Clusters within the BES-NOS group. The two groups were similar in age, IQ, and SEC, but not in pragmatic performance, as one cluster (BES-NOS-PD) scored lower than the other cluster (BES-NOS-noPD) in the ABaCo total score. A subsequent independent samples t-test confirmed the presence of a statistically significant difference between the performances of these two clusters on the ABaCo total score, with the BES-NOS-PD cluster scoring lower than the BES-NOS-noPD cluster.

To examine the extent to which the BES-NOS-PD cluster contributed to the differences in the pragmatic ability between the BES-NOS and TD groups, we conducted a second cluster analysis. This second cluster analysis, which included not only children with BES-NOS but also the control group, again yielded two clusters: one cluster consisted of all the participants belonging to the BES-NOS-PD cluster, with the addition of only one participant from the control group, and the other cluster consisted of the remaining participants from BES-NOS (BES-NOS-noPD) and the control group (BES-NOS-noPD + TD). These two groups did not differ in terms of age, IQ, and SEC, but they showed a statistically significant difference in terms of pragmatic ability. In particular, the BES-NOS-PD group performed worse than the other group in all ABaCo scales, with the sole exception of the linguistic scale.

These results, consistent with our second hypothesis, suggest that it is possible to identify some children with an impairment in pragmatic ability within the group of children with BES-NOS. In line with other studies that have identified children with undetected SPCD among children with SEN37,77,78, these results suggest that it is possible to find children with unrecognized difficulties in pragmatic ability, i.e. SPCD, even among children in the Italian BES-NOS group. Although this study did not aim to investigate the incidence and prevalence of SPCD in the population, the results seem to contradict the findings of Saul and colleagues38, who reported a prevalence of SPCD of less than 1% of the population once exclusion criteria (i.e., structural language and behavioural difficulties) were taken into account.

One possible explanation for this difference could be related to the different ages of the population included in the two studies. Namely, Saul and colleagues38 included 4 and 5 year old children in their sample, whereas we examined the pragmatic ability of older children. As suggested by Saul and colleagues, a follow-up study to examine the stability over time of SPCD diagnosis and academic achievement in these children might be informative in this regard.

Considering the age of the participants included in this study (between 7 and 16 years), the data underline a massive failure in the detection of pragmatic difficulties, not only in younger children but also in adolescents. This is even more crucial given the importance of early identification and treatment of pragmatic difficulties at a young age, considering the tremendous impact of this disorder on psychosocial outcomes and quality of life39,40. The highlighted under-recognition of difficulties in pragmatic ability in children and adolescents with BES-NOS suggests the need for greater interaction between the Italian school system and the Italian health-care system, to encourage further investigation of school difficulties in the absence of a specific diagnosis (BES-NOS). Furthermore, it supports the call for specific clinical assessment tools for SPCD, as identified in previous studies27,28.

Finally, these preliminary findings suggest that ABaCo may be an effective assessment tool for identifying children with SPCD in the Italian population.

Limits and future directions

It is crucial to keep in mind that this study is preliminary due to the small number of participants. A larger sample, more homogeneous in age range, is necessary to conduct a more comprehensive analysis of the characteristics of these children’s pragmatic difficulties and to improve the generalizability of the findings. Moreover, in light of the complexity of the labels and profiles highlighted in the present paper, it would be useful to combine measures and outcomes derived from multiple assessments that encompass a wide variety of pragmatic components, including both linguistic and non-linguistic skills. This approach would ensure to derive thorough and complete profiles of each child’s strengths and weaknesses. In addition, the potential relationship between pragmatic difficulties in children with BES-NOS and other cognitive abilities (e.g. EFs and ToM) remains to be further investigated in this population. Finally, further studies aimed at identifying pragmatic difficulties, i.e. SPCD, are warranted both in the international context and, more specifically, in the Italian reality.