Journal of Child Psychology and Psychiatry 46:2 (2005), pp 128–149 doi: 10.1111/j.1469-7610.2004.00342.

Developmental language disorders –

a follow-up in later adult life. Cognitive,
language and psychosocial outcomes
J. Clegg,1 C. Hollis,2 L. Mawhood,3 and M. Rutter3
1
University of Sheffield, UK; 2University of Nottingham, UK; 3Institute of Psychiatry, London, UK

Background: Little is known on the adult outcome and longitudinal trajectory of childhood develop-
mental language disorders (DLD) and on the prognostic predictors. Method: Seventeen men with a
severe receptive DLD in childhood, reassessed in middle childhood and early adult life, were studied
again in their mid-thirties with tests of intelligence (IQ), language, literacy, theory of mind and memory
together with assessments of psychosocial outcome. They were compared with the non language dis-
ordered siblings of the DLD cohort to control for shared family background, adults matched to the DLD
cohort on age and performance IQ (IQM group) and a cohort from the National Child Development Study
(NCDS) matched to the DLD cohort on childhood IQ and social class. Results: The DLD men had
normal intelligence with higher performance IQ than verbal IQ, a severe and persisting language dis-
order, severe literacy impairments and significant deficits in theory of mind and phonological pro-
cessing. Within the DLD cohort higher childhood intelligence and language were associated with
superior cognitive and language ability at final adult outcome. In their mid-thirties, the DLD cohort had
significantly worse social adaptation (with prolonged unemployment and a paucity of close friendships
and love relationships) compared with both their siblings and NCDS controls. Self-reports showed a
higher rate of schizotypal features but not affective disorder. Four DLD adults had serious mental health
problems (two had developed schizophrenia). Conclusion: A receptive developmental language disor-
der involves significant deficits in theory of mind, verbal short-term memory and phonological pro-
cessing, together with substantial social adaptation difficulties and increased risk of psychiatric
disorder in adult life. The theoretical and clinical implications of the findings are discussed. Key-
words: Developmental language disorder, cognitive profile, longitudinal, adult outcome, trajectory,
psychosocial outcome, psychiatric morbidity, schizophrenia. Abbreviations: DLD: developmental
language disorder; NCDS: National Child Development Study.

Approximately 3% of children present with unex-
plained difficulties in language development
(Fundudis, Kolvin, & Garside, 1979; Richman,
Stevenson, & Graham, 1982). Historically, these
children have been given a variety of labels, includ-
ing most recently specific language impairment (SLI).
Generally, all these terms are used to describe lan-
guage delay in children, without an associated
medical condition that might be causal, and whose
performance intelligence (IQ) is within the normal
range (APA, 1994; WHO, 1993).
Up to now there has been relatively little research
into the longitudinal course of developmental lan-
guage disorders (DLD), particularly beyond adoles-
cence. The few longer-term investigations have found
that receptive and expressive language impairments
tend to persist into later childhood (Aram & Nation,
1980; Cantwell, Baker, Rutter, & Mawhood, 1989;
Conti-Ramsden, Botting, Simkin, & Knox, 2001b;
Johnson et al., 1999), adolescence (Aram, Ekelman,
& Nation, 1984; Stothard, Snowling, Bishop, Chip-
chase, & Kaplan, 1998) and early adult life (Hall &
Tomblin, 1978; Mawhood, Howlin, & Rutter, 2000;
Tomblin, Freese, & Records, 1992). Deficits in lit-
eracy development and later academic attainment
become apparent over time and have been identified

Association for Child Psychology and Psychiatry, 2004.
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as significant consequences of the initial language
disorder (Aram & Nation, 1980; Conti-Ramsden
et al., 2001b; Conti-Ramsden, Knox, Botting, &
Simkin, 2002; Hall & Tomblin, 1978; King, Jones, &
Lasky, 1982; Mawhood et al., 2000; Stothard et al.,
1998). However, the samples studied have been very
heterogeneous, have varied in their exclusion criteria
and have included differing types of speech and
language impairment, ranging from phonological
speech disorders to pervasive language disorders.
The follow-up findings have all shown substantial
individual differences in outcome but, apart from the
predictive importance of low IQ and severity of lan-
guage impairment, little is known on the features
associated with variations in course. Also, few data
are available on adult functioning with respect to
cognitive functions other than IQ, language and
reading. An earlier follow-up (Mawhood et al., 2000)
of the sample reported in this paper showed an
apparent drop in performance IQ in early adult life
but this finding requires confirmation (or discon-
firmation). Furthermore, it is not known whether
language development continues in adult life,
allowing later catch-up.
It has been postulated that the underlying nature
of the persisting language disorder is linked to
 Cognitive, language and psychosocial outcomes of developmental language disorders
limitations in phonological processing (Briscoe,
Bishop, & Norbury, 2001; Stothard et al., 1998).
Within the domain of phonological processing, find-
ings have pointed to a selective impairment of the
phonological loop component in children and ado-
lescents with persistent and resolved DLD (Briscoe
et al., 2001; Conti-Ramsden, Botting, & Farragher,
2001a; Gathercole & Baddeley, 1990, 1993). Bishop,
North, and Donlan (1996) proposed that phonolo-
gical processing could be a marker for the phenotype
of heritable forms of DLD. Briscoe et al. (2001)
compared phonological processing in children with
DLD and children with mild to moderate sensori-
neural hearing loss. Both groups were impaired on
phonological processing but the hearing-impaired
children did not have the pervasive language and
literacy difficulties that are characteristic of DLD.
This confirmed that phonological processing was not
primarily dependent on auditory skills and sug-
gested that a deficit in phonological processing may
not be a sufficient cause for the language and lit-
eracy difficulties in DLD.
Some language-impaired children are reported to
have difficulty with the processing and compre-
hension of inferential meaning (Bishop & Adams,
1992; Letts & Leinonen, 2001). It is not certain if
this is due to their linguistic impairment or more
specifically to problems in the pragmatics of lan-
guage and communication. The concept of theory of
mind has been linked to inferential meaning but it
has not been extensively researched in DLD. This is
partly because social and behavioural difficulties
have only recently been associated with the disorder
(Bishop & Adams, 1989; Botting & Conti-Ramsden,
2000; Farmer, 2000; Howlin, Mawhood, & Rutter,
2000).
Studies have addressed the role of language in
theory of mind development. Ziatus, Durkin, and
Pratt (1998) reported that children with SLI had in-
tact theory of mind compared to children with aut-
ism. Wolfe, Want, and Siegel (2002) assessed theory
of mind in deaf children with no or limited oral lan-
guage who were categorised as either native or late
British Sign Language signers. The late signers had
theory of mind deficits relative to the native signers
even when verbal mental age and executive func-
tioning were controlled for, thus highlighting that
early interactional language experience is essential
to theory of mind development. De Villiers (2000)
argued for the role of grammatical understanding as
implicit in the ability to pass theory of mind tasks.
Indeed, the capacity of individuals with Asperger’s
Syndrome and High Functioning Autism (HFA) to
typically pass theory of mind tasks has been attrib-
uted to their higher language and IQ levels (Bowler,
1992; Ozonoff, Pennington, & Rogers, 1991; Perner
& Wimmer, 1985). Preliminary research has estab-
lished some association between language and the-
ory of mind. Still to be determined is whether
individuals with DLD pass or fail theory of mind
129
tasks and if this is due to the language demands of
the tasks or because of a theory of mind deficit.
Recent research findings indicate that children
with DLD can also develop social, emotional and
behavioural problems (Botting & Conti-Ramsden,
2000; Cantwell et al., 1989; Howlin et al., 2000). To
date, little is known on the extent to which these
problems persist, or on the degree to which they are
preceded by similar problems in earlier childhood.
Most importantly, knowledge is lacking on whether
such problems are mainly a function of language
delay, associated cognitive difficulties (including
theory of mind deficits) or family circumstances.
A higher prevalence of psychiatric disorders in
childhood has been identified in speech and lan-
guage impaired children compared to those without
(Baker & Cantwell, 1987a,b; Beitchman et al.,
1996a; Cantwell & Baker, 1977). A developmental
impairment in receptive language seems to carry the
greatest risk of psychiatric disorder (Baker & Cant-
well, 1987a, b; Beitchman, Nair, Clegg, Ferguson, &
Patel, 1986; Beitchman et al., 1996a). The main
types of childhood psychopathology associated with
DLD appear to be anxiety-related symptoms, social
and behavioural difficulties and attention-deficit
problems (Baker & Cantwell, 1987a, b; Beitchman
et al., 1986; King et al., 1982). Longitudinal follow-
ups of these children have found that psychiatric
disorders tend not to resolve and that the incidence
of psychiatric disorder increases on entry into ado-
lescence (Baker & Cantwell, 1987b; Beitchman
et al., 1996a). However, methodological issues,
including sample heterogeneity and referral bias,
complicate the interpretation of the findings. As a
result, the mechanisms explaining the links are not
known (Beitchman, 1985; Beitchman et al., 1996a;
Beitchman, Cohen, Konstantareas, & Tannock,
1996b; Howlin & Rutter, 1987).
In summary, the findings from previous research
have left a need to determine the range of cognitive
deficits in adult life among individuals diagnosed in
childhood as having DLD, to examine the inter-
relationships among cognitive features, to delineate
any changes in cognitive functioning that take place
during early adult life and to examine psychosocial
functioning further into adult life.
In order to tackle these questions, we turned to a
sample of individuals with a diagnosis of severe de-
velopmental receptive language disorder (DLD) first
studied in childhood (Time 1) (Bartak, Rutter, & Cox,
1975) and followed up through middle childhood
(Time 2) (Cantwell et al., 1989) and into their early
twenties (Time 3) (Howlin et al., 2000; Mawhood et
al., 2000). Initially, they had been investigated in
order to compare DLD with autism but this com-
parison was not of prime interest to this present
study. Rather, there were two key needs. First, it was
necessary to determine how far the adult outcome
was a function of family circumstances rather than
the presence of DLD. In order to tackle that issue, we
130 J. Clegg et al.
chose to study the adult non-language-disordered
siblings of the DLD subjects. Second, it was neces-
sary to determine whether the adult outcome was a
function of general cognitive impairment. To exam-
ine this question we selected a new IQ-matched
group of adult controls without DLD. As a further
control of family background and also to provide a
control for childhood cognitive level, we used a
sample from the National Child Development Study
(NCDS). A subsample of men from the NCDS at age
33 years was matched to the DLD cohort on child-
hood performance IQ and parental social class.
With respect to cognition and language, the main
hypotheses that we set out to test were that: 1) the
cognitive decline found in the early twenties would be
followed by a continuing impairment in all language
skills; 2) the individual differences in language out-
come would be a function of a phonological processing
deficit; 3) deficits in language and non-verbal cognit-
ive skills would be associated with a deficit in theory of
mind; and 4) there would be substantial positive cor-
relations among the different cognitive features.
Within psychosocial functioning, four main hypo-
theses were tested: 1) that the individuals in the DLD
cohort would continue to have impaired levels of
social adaptation in their mid-thirties and that this
would show continuities with the impairments found
in the early twenties; 2) that the impaired social
adaptation would be specific to the unresolved DLD
and independent of intelligence, family background
and social class; 3) that social impairments would be
more strongly related to deficits in theory of mind
and the pragmatics of language than DLD as such; 4)
that adults with unresolved DLD would continue to
be at risk for psychiatric morbidity as they moved
through their twenties and into their mid-thirties
and that this would be specifically associated with
the DLD rather than intelligence, family background
or social class.
Design of mid-thirties follow-up
Subjects
DLD cohort. The DLD cohort had initially been
identified through six special units (attached to
hospitals) and six special schools located throughout
the UK (Bartak et al., 1975). Inclusion criteria
required that the subjects be between 4 and 9 years
of age with a performance IQ of at least 70, severe
delays in receptive and expressive language and no
identifiable aetiology. Twenty-three boys were
recruited to form the DLD cohort. When seen in their
early twenties (Time 3), three members from the DLD
cohort were found to have bilateral hearing losses
exceeding 40 dB, which had not been identified
when they were first assessed. These three indi-
viduals were excluded from all subsequent follow-up
analyses (Howlin et al., 2000; Mawhood et al., 2000).
Final adult outcome. The twenty DLD subjects
recruited to and assessed at the Time 3 phase (early
twenties) were traced and contacted. One of the
subjects had declined to participate in the cognitive
assessment at Time 3 and did so again. A further two
DLD subjects withdrew from this mid-thirties
assessment, reducing the final sample to 17 DLD
subjects. At the 30-year follow-up (Time 4), the DLD
cohort consisted of 17 male adults with a mean age
of 36 years, 2 months (range 33:0 to 38:1 years; SD
1.25).
Siblings (Comparison 1). There were 16 non-lan-
guage-disordered siblings of the DLD cohort (10
males and 6 females) with a mean age of 36 years
10 months (range 25:0 to 44:0 years; SD 6.04), and
no history of hearing, developmental, medical or
neurological disorders. Once face-to-face contact
was made with the DLD adult and his family, per-
mission was obtained to contact a sibling. A male
sibling within 5 years of age to the DLD adult was the
first choice. Second choice was a male sibling out-
side of this 5-year range. Where neither was poss-
ible, a female sibling closest in age was selected. An
appointment was then arranged to visit and assess
the sibling in his or her own home. One DLD adult
had no sibling. All of the siblings contacted agreed to
participate in the study. None of the 16 siblings who
were contacted and participated were reported by
themselves or family members to have any history of
DLD or related disorders. Recruiting siblings relied
on the goodwill of the DLD subjects and their famil-
ies. It is possible that there were other siblings who
did have positive histories of DLD but these were not
reported. It is worth noting that when the DLD sub-
jects and their siblings were children, DLD was not
as well recognised as it is now and that some siblings
may have had more subtle unidentified language or
even literacy impairments which would be recog-
nised today. Construction of an accurate profile of
heritability would only have been possible by
assessing all of the siblings of the DLD subjects; this
was not a specific aim of the study. The siblings were
used as a comparison group in both the cognitive
and psychosocial analyses at the mid-thirties
assessment.
IQ match control group (IQM) (Comparison 2).
There were 17 non-language-disordered males with
a mean age of 36 years and 8 months (range
34:1 years to 39:1 years; SD 2.2) matched to the
DLD cohort on age, gender and performance IQ, with
no history of hearing, developmental, medical or
neurological disorders. This comparison group con-
sisted of volunteers recruited from the Nottingham
area via advertisements in local employment centres
and at the Queens Medical Centre, University of
Nottingham. Performance IQ was used as the
matching criterion due to the unusual and relatively
 Cognitive, language and psychosocial outcomes of developmental language disorders
specific intelligence profile of DLD, in which verbal
IQ is usually lower than performance IQ. Matching
on verbal and performance IQ would also have in-
creased the risk of this comparison group having a
specific language difficulty. Initially, the short form
of the Wechsler Adult Intelligence Scale – Revised
(WAIS-R) (Wechsler, 1981) was administered to
screen volunteers on performance IQ score. If this
matched the mean performance IQ score of the DLD
cohort (within a 3-point range either side of the
mean) they completed the entire cognitive and lan-
guage assessment battery. The IQM group was used
as a comparison group in the cognitive analyses at
the mid-thirties assessment.
NCDS (Comparison 3). The National Child Devel-
opment Study (NCDS) was used to identify a gen-
eral population comparison group matched to the
DLD cohort on childhood performance IQ and
parental social class as assessed at the initial
assessment (Time 1). NCDS is a prospective study
of all children born in Britain in one week in 1958.
After the initial sweep, childhood follow-ups took
place at ages 7 (Davie, Butler, & Goldstein, 1972),
11 (Wedge, 1969) and 16 years (Fogelman, 1983).
The follow-ups included medical examinations and
educational testing, interviews with parents, and
data collection from teachers and schools. The
adult contacts at ages 23 and 33 years involved
interviews and questionnaires completed by the
cohort members themselves (Ferri, 1993).
A subsample of men from the NCDS cohort at age
33 years with complete data in a previous study of
adult psychosocial outcome (Maughan, Collishaw, &
Pickles, 1999) was re-examined (Maughan & Col-
lishaw, 1999). Boys scoring within a )1.87sd to
+.4sd range on a general ability test administered at
age 11 years were included. (The general ability test
is a standardised 80-item group-based general abil-
ity test which was administered to cohort members
at age 11 years. The test was designed by the Na-
tional Foundation for Educational Research and
included alternate verbal and non-verbal items.)
This range matched the performance IQ range of the
DLD cohort measured at a mean age of 8 years and
2 months.
Individuals with any language/sensory/medical/
neurological problems at age 11 were then excluded,
as were subjects who had ever attended a special
school and those with any signs of speech and lan-
guage problems (as assessed by parents and teach-
ers). A modified Rutter A-scale (for parents) assessed
behaviour problems at age 11 years. This scale
included all the standard items, except for items 1
(restless), 16 (fussy), 17 (lies) and 18 (bullies others).
Boys were included regardless of levels of behaviour
problems.
At the initial childhood recruitment, 28.9% of the
DLD cohort had fathers in professional/clerical
occupations and 69.1% had fathers in manual
131
occupations (Bartak et al., 1975). These two social
groups were stratified exactly in the NCDS subjects.
After exclusions and matching on parental social
class, 1384 subjects met the inclusion criteria and
formed the NCDS cohort. The NCDS cohort was used
as a comparison group for the psychosocial out-
comes at the mid-thirties assessment.
Longitudinal cognitive and language analy-
sis. Longitudinal cognitive data included verbal
and performance IQ, language and literacy assess-
ments in childhood (Time 1), middle childhood (Time
2), early twenties (Time 3) and mid-thirties (Time 4).
Recruitment issues, particularly in middle child-
hood, the identification of 3 subjects with hearing
impairment at Time 3 and the general effect of
attrition over time had affected the DLD cohort. To
construct and analyse a valid developmental cognit-
ive trajectory, only those DLD subjects assessed at
each of the four time points were included in the
longitudinal analysis. The final cohort sizes were 17
DLD subjects at the initial childhood assessment
(Time 1), early-twenties assessment (Time 3) and the
mid-thirties assessment (Time 4). At the middle-
childhood assessment (Time 2) data were only
available for 9 DLD subjects. These 9 DLD individ-
uals participated in all of the other assessment time
points and their scores were similar to the complete
samples at Times 1, 2 and 3. The final cohort sizes
and mean chronological ages are shown in Table 1.
Procedure and measures – cognition and language
Each subject was administered a battery of cognitive
measures over two to three sessions lasting
approximately three to four hours depending on the
circumstances of each subject. The DLD cohort and
siblings were assessed individually in their own
homes located throughout the UK.
The IQM group was assessed in a clinic room in the
Developmental Psychiatry section at Queens Medical
Centre, University of Nottingham. The cognitive
measures used at the final adult outcome assess-
ment are shown in Table 2. The cognitive and lan-
guage measures used at each assessment of the DLD
cohort from childhood to adult life are shown in
Table 1.
Intelligence, language and literacy measures
Thirty-year follow-up (Time 4). A short form of the
Wechsler Adult Intelligence Scales – Revised UK
(WAIS-RUK) (Wechsler, 1992) was employed. This
comprised three verbal subtests: comprehension,
vocabulary and arithmetic, and the two performance
subtests, block design and object assembly. These
five WAIS-R subtests were the best predictors at
Time 3 of the full-scale WAIS-R IQ score. The British
Picture Vocabulary Scales (BPVS) (Dunn, Dunn,
Whetton, & Pintilie, 1982) measured receptive
132 J. Clegg et al.

Table 1 Longitudinal assessments of IQ, language and literacy used in the DLD cohort

Time 1 Initial assessment in Time 2 Middle Time 3 Early Time 4

childhood N ¼ 17 childhood N ¼ 9 twenties N ¼ 17 Mid-thirties N ¼ 17

Mean age 9.11 years 13.04 years 24.03 years 36.02 years
Verbal IQ Wechsler Intelligence Not assessed Wechsler Adult Intelligence WAIS-RUK
Scale for Children (WISC) Scales (WAIS-R)
Performance IQ WISC WISC WAIS-R WAIS-RUK
Receptive Reynell Developmental Reynell British Picture Vocabulary Scales BPVS Oral comprehension test
language Language Scales (BPVS) Oral comprehension test
Expressive Reynell Developmental Reynell Expressive One Word Picture EOPVT
language Language Scales Vocabulary Test (EOPVT)
Literacy Graded word reading test R1 Not assessed Gray oral reading test form A Wechsler Objective Reading
Silent reading test A Schonell graded word spelling test A Dimensions (WORD)
Edinburgh reading tests

Table 2 Cognitive and language measures used at the mid-thirties follow-up (Time 4)

Cognitive domain Assessment

Intelligence Short form of the WAIS-R UK (Wechsler, 1992)

Literacy Wechsler Objective Reading Dimensions (WORD) (Wechsler, 1993)
Expressive language Expressive One-word Picture Vocabulary test (EOPVT) (Gardner, 1979)
Receptive language British Picture Vocabulary Scales (BPVS) (Dunn et al., 1982)
Syntactic and semantic understanding Oral Comprehension Test (Mawhood, 1995) based
on the Neale Reading Test (1958)
Theory of mind The Eyes Task (Baron-Cohen et al., 1997)
Strange stories (Happé, 1994)
Awkward Moments test (Heavey et al., 2000)
Visual and verbal memory Doors & People (Baddeley et al., 1994)
Working memory Sentence repetition form A from the Multi-lingual aphasia examination
(Benton & deS Hamsher, 1989)
Phonological processing Adult test of nonword repetition (Gathercole & Baddeley, 1996)

vocabulary, and the Oral comprehension test
(Mawhood, 1995), based on the Neale Reading Test
(Neale, 1958), was used to assess the overall process
of oral comprehension. In this test, three passages of
increasing length and complexity are read to the
subject who then answers questions which test his
understanding of the passages heard. The Expres-
sive One-Word Picture Vocabulary Test (EOPVT)
(Gardner, 1979) provided a measure of expressive
language. The Wechsler Objective Reading Dimen-
sions (WORD) (Wechsler, 1993) provided a meas-
ure of basic reading, reading comprehension and
spelling.
Longitudinal analysis. The Wechsler Intelligence
Scale for Children (WISC) (Wechsler, 1949) was
used at the initial assessment and the first follow-
up into middle childhood (verbal IQ was not as-
sessed). At Time 3, the WAIS-R (Wechsler, 1981)
was used. Receptive and expressive language was
measured with the Reynell Developmental Lan-
guage Scales (Reynell, 1969) at the initial assess-
ment and in middle childhood. At Time 3 (early
twenties), the BPVS and the Oral comprehension
test (Mawhood, 1995) were used to assess receptive
language, whereas the EOPVT measured expressive
language. Literacy was assessed at the initial
childhood assessment and early twenties but not in
middle childhood. The literacy assessments em-
ployed have generally measured reading accuracy
(Gray, 1967; Schonell & Schonell, 1960; Wechsler,
1993), reading comprehension (McBride &
McNaught, 1985; Pollit, 1977; Schonell & Schonell,
1960; Wechsler, 1993) and spelling (Schonell &
Schonell, 1960; Wechsler, 1993). A summary of
this is given in Table 1.
Memory and phonological processing. Memory was
assessed at the 30-year follow-up but not in the
three previous studies. The Adult test of nonword
repetition (ANrep) (Gathercole & Baddeley, 1996)
was used to assess phonological processing. This
consists of 28 nonsense words ranging from 2 to 6
syllables, categorised into words that involve simple
and complex articulation. A score of one is given for
each correct repetition. The Sentence repetition test
(Benton & deS. Hamsher, 1989) was used as a
verbal short-term memory measure. This is a sub-
test of the Multi-lingual Aphasia examination
(Benton & deS. Hamsher, 1989). Form A was used,
which has 14 sentences of increasing length. A
score of one is awarded for each correct repetition.
The Doors and People test (Baddeley, Emslie, &
Nimmo-Smith, 1994) was used as a general mem-
ory assessment. This is standardised on an adult
population and measures visual and verbal recall
 Cognitive, language and psychosocial outcomes of developmental language disorders
and recognition. Four scales were chosen for ana-
lysis: total memory, combined visual memory,
combined verbal memory and overall forgetting.
Theory of mind. Theory of mind was also not pre-
viously assessed in the DLD cohort. Three second-
order theory of mind tasks were used. By using
three tasks, the validity of each task could be
compared and a composite measure obtained. The
Eyes task (Baron-Cohen, Joliffe, Mortimore, &
Robertson, 1997) consists of 25 different male and
female faces. The subject is asked to choose which
of two words best describes what the person in the
photograph is thinking or feeling. The response is
scored as either correct or incorrect with a possible
maximum score of 25. The original Eyes task was
used because data collection had finished prior to
the construction of the revised version (Baron-
Cohen, Wheelwright, Hill, Raste, & Plumb, 2001).
The Strange Stories task (Happé, 1994) consists of
24 short stories or vignettes each accompanied by
a picture and two test questions; the comprehen-
sion questions ‘Was it true what X said?’ and the
justification question ‘Why did X say that?’ There
were 12 types of story and two examples of each
story type. The 12 story types comprised of lie,
white lie, joke, pretend, misunderstood, persuade,
appearance, reality, figure of speech, sarcasm,
double bluff and contrary emotions. The responses
to both the comprehension and justification ques-
tions were scored as either correct or incorrect. In
all cases, a justification in terms of mental or
physical states was possible. A justification was
incorrect if it involved errors about the facts given
in the story or if it involved an incorrect inference
as a reason for a story character’s behaviour. If a
subject gave one correct answer and one inappro-
priate answer, the correct answer was taken. If an
answer appealed to both physical and mental
states, the justification was scored as a mental
state. Finally, the Awkward Moments test (Phillips
& Newman, 1994; Heavey, Phillips, Baron-Cohen,
& Rutter, 2000) is a computer-based task which
consists of seven well-known television advertise-
ments and a clip from the British television series
Coronation Street. The test films are set in a variety
of situations and feature characters of different
ages in various roles and relationships. The test
clips show a character experiencing a socially
awkward or unpleasant moment at some point
during the clip. The items are programmed to run
on a laptop computer from a CD ROM. After each
item, two questions appear on the screen. The first
question is a theory of mind question and the
second a general comprehension question to as-
sess whether the subject has understood the social
situation. In total, there are 8 comprehension
questions and 8 theory of mind questions. Re-
sponses are scored as either correct or incorrect.
The Awkward Moments test is considered a more
133
naturalistic way of measuring more subtle theory
of mind deficits in adult populations.
Procedure and methods – psychosocial functioning
Data collection methods for the DLD cohort and
siblings involved standardised interviews with the
subject and an informant (a parent or close relative
of the subject). Subjects completed self-report
assessments to identify possible indicators of adult
psychiatric morbidity. The social adaptation out-
come and psychiatric morbidity of the NCDS cohort
at age 33 years was identified and calculated by
Maughan and Collishaw (1999).
Social adaptation
The informant and subject versions of the socio-
emotional functioning interview (SEF (I) and SEF (S))
(Rutter et al., 1988) were used to gain information
regarding the social adaptation of the DLD cohort
and the siblings. The subject version was used to
gain information from the subject. The informant
version was conducted with an informant (parent or
close relative) to verify the information given by the
subject. Informants for the DLD cohort consisted of
mothers only (n ¼ 10), fathers only (n ¼ 1), mother
and father (n ¼ 4) and siblings (n ¼ 2). Where dis-
agreement occurred, a coding was chosen using the
researcher’s discretion.
The SEF (S) and (I) interviews obtained information
pertaining to academic outcome and educational
provision (school placement, examination attain-
ment and type of further education), employment
post 16 years (current employment status, history
and dismissals), independent living post 16 years,
relationships (romantic, friendships and acquaint-
ances), family life, receipt of state benefits and
housing. Details of the categories are shown with the
results in Tables 8 to 11. Rating criteria can be found
in the SEF (S) and (I) (Rutter et al., 1988).
Pragmatic analyses of expressive language
As part of the assessment of the DLD cohort in their
early twenties (Time 3), a pragmatic analysis of the
expressive language of the DLD cohort was comple-
ted (Eales, 1993). This analysis utilised the methods
developed by Bishop and Adams (1989) which
measured appropriate and inappropriate features of
pragmatic language ability. A total inappropriacy
score (defined as no. of inappropriate utterances/
total no. of utterances including empty turns) was
obtained from this analysis (Eales, 1993). In addi-
tion, a communicative intention rate was also cal-
culated for the DLD cohort (Eales, 1993), defined as
the count of all utterances that were inappropriate
because a relevant communicative intention was
lacking. Examples include (a) utterances involving
the positive presence of an irrelevant intention such
134 J. Clegg et al.
as inappropriate persistence or reversion to a previ-
ous topic and (b) utterances that are inappropriately
uninformative. The total inappropriacy score and the
communicative intention rate were incorporated into
a correlation analysis of social adaptation, final
language outcome and cognition.
Psychiatric morbidity
The Malaise Inventory (Rutter, Tizard, & Whitmore,
1970) is a 24-item self-completion scale with estab-
lished reliability and validity (Rodgers, Pickles,
Power, Collishaw, & Maughan, 1999) which was
used to assess affective symptomatology in the DLD
adults and siblings. The Malaise scores of the NCDS
cohort at 33 years were also included in the analysis
(Maughan & Collishaw, 1999).
The Schizotypal Personality Questionnaire (SPQ)
(Raine, 1991) is a self-report scale modelled on DSM-
III R criteria for schizotypal personality disorder. The
SPQ was used to identify features of schizotypal
personality disorder in the DLD cohort and the sib-
lings. It contains nine subscales for all of the nine
schizotypal personality traits: ideas of reference,
excessive social anxiety, odd beliefs or magical
thinking, unusual perceptual experiences, odd or
eccentric behaviour, no close friends, odd speech,
constricted affect and suspiciousness. Altogether
there are 74 items. The subject read the questions
and either agreed or disagreed with the question by
circling a yes or no answer. Raine (1991) assessed
the presence of each schizotypal trait on a 3-point
scale (1 ¼ absent, 2 ¼ subthreshold, 3 ¼ threshold).
Subjects had to have five traits out of the nine at
threshold for a DSM-III R diagnosis of schizotypal
personality disorder.
Literacy levels were a concern in the DLD cohort.
To ensure that the DLD subjects understood the
items, the interviewer (JC), who is a speech and
language therapist, accompanied each item with
simplified instructions as appropriate to each
subject’s level of understanding.
When participants had histories of mental health
problems, medical notes from the general practi-
tioners (GPs) and psychiatrists were obtained and
reviewed by a research psychiatrist (CH) in order to
provide information regarding the exact nature of
their psychiatric diagnosis. Psychiatric diagnoses
were made using DSM-IV criteria (APA, 1994) after
combining all available clinical information. The
Table 3 Intelligence quotients on the WAIS-RUK at the mid-thirties assessment
DLD (n ¼ 17) Sibling (n ¼ 16)
Verbal IQ Mean (SD) 80.7 (8.0) 102.1 (8.6)
Performance IQ Mean (SD) 92.1 (7.0) 108.0 (9.2)
Full scale IQ Mean (SD) 84.4 (8.3) 105.0 (8.0)
*p < .05; **p < .01; ***p < .001.
DLD ¼ developmental language disorder group.
IQM ¼ IQ-matched comparison group.
DLD cohort was not seen for a clinical psychiatric
assessment at this time point.
Statistical analyses
Cognitive and language outcome data. Raw scores
were used to compare group differences in language
and literacy measures (BPVS, EOPVT, Oral Com-
prehension Test and WORD) in the mid-thirties
(Time 4). Standardised and age equivalent (AE)
scores were used to analyse longitudinal changes in
IQ, language and literacy measures from Time 1 to
Time 4. Multivariate analysis of variance (MANOVA)
was performed to assess group differences at Time 4.
Where significant, univariate analyses of variance
(ANOVA) with verbal and full-scale intelligence as
covariates were conducted on each variable. The
Bonferroni correction test was used to adjust the
observed significance level according to the number
of comparisons made. The Student Newman Keuls
(SNK) post hoc test was used to further explore dif-
ferences between groups. Correlations were com-
pleted using Pearson product moment correlation.
All reported tests of significance are two sided.
Psychosocial outcome data. The social adaptation
variables were analysed using cross tabulations. A
Fisher exact test (2 · 2 tables) and chi-squared test
with continuity correction (2 · r tables) were used
when cells had small expected frequencies. A one-
way analysis of variance (ANOVA) compared group
differences on the Malaise Inventory. Independent t-
tests analysed self-reported SPQ scores between the
DLD cohort and the siblings. Correlations were
completed using the Pearson product moment cor-
relation. All reported tests of significance are two-
sided.
Results
Cognition and language
Intelligence levels in DLD in the mid-thirties. In
their mid-thirties, the mean IQ scores of the DLD
adults were within the normal range (full-scale IQ 1
SD below the population mean) with verbal IQ sig-
nificantly lower than both comparison groups and
performance and full-scale IQ significantly lower
than the siblings (see Table 3). The DLD cohort
(p < .05) and the siblings (p < .05) had a significantly
IQM (n ¼ 17) ANOVA F ratio Post hoc pairwise comparisons
93.2 (1.0) 11.9*** DLD < Siblings*** DLD < IQM**
89.3 (6.2) 7.1** DLD < Siblings**
91.3 (6.6) 9.8*** DLD < Siblings***
 Cognitive, language and psychosocial outcomes of developmental language disorders
higher performance IQ than verbal IQ (Wechsler,
1992).
Changes in intelligence with age. At the initial
childhood assessment (Time 1), the DLD boys had a
mean verbal IQ of 74.5 (SD 7.9) (n ¼ 14) and a higher
mean performance IQ of 89.2 (SD 8.0) (n ¼ 17). In
middle childhood, performance IQ remained at a
similar level with a mean of 92.3 (SD 7.0) (n ¼ 9). In
the early twenties, verbal IQ remained at about the
same level with a mean of 78.1 (SD 8.0) as compared
with the initial score of 74.5 (SD 7.9) (n ¼ 17).
However, between middle childhood (Time 2) and the
early twenties (Time 3), there was a drop of 14 points
in mean performance IQ from 92.3 (SD 7.0) to 78.0
(SD 6.7) (n ¼ 17) even though verbal IQ had re-
mained relatively stable. However, performance IQ
measured in the mid-thirties (Time 4) was similar to
that measured in childhood and this failed to sup-
port the suggestion (at Time 3) of a drop in per-
formance IQ in adult life.
Language profile in DLD in the mid-thirties. The
DLD cohort had the lowest language scores across
the three measures used at follow-up (see Table 4).
The MANOVA revealed a significant main effect of
group (F(6, 90) ¼ 6.3; p < .001) for language. The
ANOVAs and post hoc comparisons revealed sig-
nificant and severe receptive and expressive lan-
guage deficits in the DLD adults. Although the DLD
cohort had lower oral comprehension scores than
the IQM group, this did not reach statistical sig-
nificance.
Changes in language functioning with
increasing age
Standardised scores and age-equivalent scores are
reported for the receptive and expressive language
assessments used at each time point. The childhood
basal mean z-score for receptive language was )1.1
(SD 2.0) (age-equivalent score (AE) 5;02 years) and
.40 (SD 2.2) (AE 3;04 years) for expressive language.
At the first follow-up in middle childhood, all 9 of the
DLD boys assessed scored above the ceiling level of
6 years (raw score 72+) on both the receptive and
expressive scales, showing an improvement in
Table 4 Raw scores on tests of language at the mid-thirties assessment
Language task DLD (n ¼ 17) Sibling (n ¼ 16)
BPVS MS ¼ 150 Mean (SD) 107.2 (7.5) 136.0 (4.4)
EOPVT MS ¼ 67 Mean (SD) 28.5 (8.5) 47.0 (5.9)
Oral comprehension Mean (SD) 10.8 (4.1) 15.0 (2.1)
task MS ¼ 17
*p < .05; **p < .01; ***p < .001.
DLD ¼ developmental language disorder group.
IQM ¼ IQ-matched comparison group.
MS ¼ Maximum score.
135
language ability. By the early twenties, language
levels had risen to about 11 years, and the mean
standardised score for receptive language was 57.2
(SD 6.3) (AE 10;09 years) and 76.7 (S.D 8.1) for
expressive language (AE 11;06 years). Language
showed little further development over the next
decade. The receptive language standardised score
in the mid-thirties (Time 4) was 62.2 (SD 7.2) (AE
11;09 years) and the expressive standardised score
83.4 (SD 8.5) (AE 11;01 years). The oral compre-
hension raw score in the early twenties was 10.1 (SD
3.8) with little change at 10.8 (SD 4.1) in the mid-
thirties. Analysis of change over time using repeated
measures t-tests for the BPVS, EOPVT and the oral
comprehension task from early twenties to mid-
thirties revealed no significant differences from Time
3 to Time 4 for these three language assessments.
At the mid-thirties assessment, the mean receptive
standardised score for the siblings and IQM group
were 98.0 (SD 6.2) (AE 18;00 years) and 85.6 (SD
6.1) (AE 16;01 years) (1 subject at ceiling) respect-
ively. Mean expressive standardised scores for the
siblings were 107.9 (SD 8.2) (AE 13;09 years) (5
subjects at ceiling) and 100.4 (SD 7.1) (AE
14;08 years) for the IQM group.
The longitudinal analysis of the DLD cohort
showed that receptive and expressive language
impairments persisted from childhood into adult life
even though intelligence was within the normal
range. The combination of normal performance IQ
(>70) with severe language disorder used as dia-
gnostic criteria for DLD at the initial childhood
assessment was confirmed at adult follow up.
Literacy levels
At the mid-thirties follow-up, the DLD cohort had the
lowest literacy scores across all three WORD sub-
tests (see Table 5). Both the comparison groups had
superior literacy abilities that reached ceiling levels.
A MANOVA revealed a significant main effect of
group (F(6, 90) ¼ 9.6; p < .001) for literacy. The
ANOVAs and post hoc comparisons showed sig-
nificant and severe literacy deficits in the DLD adults
compared with both the siblings and the IQM group.
Only age-equivalent scores were available for the
longitudinal literacy analysis. The literacy abilities of
Post hoc pairwise
IQM (n ¼ 17) ANOVA F ratio comparisons
138.5 (5.7) 11.5*** DLD < Siblings, IQM***
48.4 (6.7) 8.5*** DLD < Siblings, IQM***
13.4 (3.4) 6.7* DLD < Siblings***
136 J. Clegg et al.

Table 5 Raw scores for reading and spelling (on the WORD test) at the mid-thirties assessment

WORD DLD Sibling IQM ANOVA Post hoc pairwise

subtest (n ¼ 17) (n ¼ 16) (n ¼ 17) F ratio comparisons

Basic reading MS ¼ 55 Mean (SD) 36.2 (8.8) 50.5 (6.9) 51.8 (3.8) 15.1** DLD < Siblings, IQM***
Reading comprehension Mean (SD) 21.9 (6.0) 32.8 (5.3) 33.1 (3.0) 17.8*** DLD < Siblings, IQM***
MS ¼ 38
Spelling MS ¼ 50 Mean (SD) 28.0 (3.4) 40.3 (9.6) 41.1 (6.5) 7.5** DLD < Siblings, IQM***

*p < .05; **p < .01; ***p < .001.

DLD ¼ developmental language disorder group.
IQM ¼ IQ-matched comparison group.
MS ¼ Maximum score.

the DLD boys at the initial childhood assessment
were impaired, with only 7 of the 17 boys being able
to complete the reading comprehension task (Silent
reading test A), but all 17 completing the reading
accuracy test (Graded word reading test R1). Literacy
was not assessed in middle childhood (Time 2). In
their early twenties (Time 3), the mean age equival-
ents obtained by the DLD cohort on reading
accuracy (Gray Oral Reading Test), reading compre-
hension (Edinburgh reading tests) and spelling
(Schonell Graded Word Spelling Test) were all
around 9 years, with spelling the weakest area of
ability. In their mid-thirties, the mean standardised
scores for basic reading, reading comprehension and
spelling were 70.8 (SD 9.3) (AE 9;08 years), 70.8
(SD 7.6) (AE 9;05 years) and 65.2 (SD 5.6) (AE
9;05 years) respectively.
Literacy standardised and age-equivalent scores
for the sibling group and the IQM group at Time 3
are reported here. The mean standardised score on
basic reading for the siblings was 102.4 (SD 8.2)
(AE 15;09 years) (10 subjects at ceiling) and 105.4
(SD 9.1) (AE 16;07 years) (7 subjects at ceiling) for
the IQM group. Mean reading comprehension
standardised scores for the siblings and IQM group
were 107.5 (SD 19.1) (AE 16;00 years) and 104.2
(SD 12.7) (AE 16;01 years) respectively. The mean
spelling standardised score for the siblings was
100.0 (SD 9.2) (AE 14:09 years) (1 subject at ceil-
ing) and 100.4 (SD 11.1) (AE 15:00 years) for the
IQM group.
Visual and verbal recall and recognition
Four scales from the Doors and People test were
used to gain an overall measure of memory ability.
The DLD cohort had lower mean scores across the
four scales; however, a MANOVA to investigate group
differences across the four scales was non-signific-
ant. Total memory: The DLD cohort had the lowest
mean scaled score of 6.8 (SD 3.5), with both the
siblings (mean 10.2, SD 3.0) and the IQM group
(mean 10.5, SD 2.8) performing at a similar average
level. Combined visual memory: The DLD cohort
gained the lowest mean scaled score of 7.7 (SD 2.7)
and the siblings the highest at 10.6 (SD 1.5) with the
IQM group at 9.5 (SD 2.5). Combined verbal memory:
The mean scaled score of the DLD cohort was the
lowest at 7.2 (SD 3.2) and the IQM group the highest
at 11.4 (SD 3.4) with the siblings slightly lower at 9.9
(SD 3.5). Overall forgetting: The DLD cohort had the
lowest overall forgetting score of 8.6 (SD 3.5). The
mean scores of the siblings at 10.1 (SD 2.2) and the
IQM at 9.5 (SD 3.1) were slightly higher than
the DLD cohort. Overall, visual and verbal recall and
recognition was poorer than the comparisons but did
not reach statistical significance, with no tendency
towards material selectivity.
Short-term verbal memory (sentence repeti-
tion). From a possible total score of 14, the DLD
cohort had the lowest mean score of 6.7 (SD. 1.8)
compared with 12.0 (SD. 2.5) for the siblings and
12.3 (SD. 1.6) for the IQM group. This resulted in a
significant overall between group effect (F(2,
45) ¼ 19.7; p < .001). The post hoc SNK test con-
firmed significant differences between the DLD co-
hort and both comparison groups (DLD < Siblings:
IQM p < .001).
Phonological processing. The mean scores on the
ANrep for total score and articulatory complexity are

Table 6 Phonological processing scores on the ANrep at the mid-thirties assessment

ANrep DLD (n ¼ 17) Sibling (n ¼ 16) IQM (n ¼ 17) ANOVA F ratio Post hoc pairwise comparisons

Raw score MS ¼ 28 Mean (SD) 11.6 (5.4) 23.3 (2.8) 23.6 (3.0) 29.5*** DLD < Siblings, IQM***
Simple MS ¼ 14 Mean (SD) 6.0 (.80) 11.5 (.30) 11.8 (.43) 17.4*** DLD < Siblings, IQM***
Complex MS ¼ 14 Mean (SD) 5.5 (.63) 11.6 (.50) 11.8 (.40) 25.6*** DLD < Siblings, IQM***

*p < .05; **p < .01; ***p < .001.

DLD ¼ developmental language disorder group.
IQM ¼ IQ-matched comparison group.
MS ¼ Maximum score.
 Cognitive, language and psychosocial outcomes of developmental language disorders 137

shown in Table 6. A univariate ANOVA on the ANrep

total score revealed a significant effect (F(2,
45) ¼ 29.5; p < .001). A post hoc SNK test identified
a significant phonological processing deficit in the
DLD cohort at the .001 level against both compar-
ison groups. Three way analysis of variance with
ANrep score as the dependent variable gave a sig-
nificant effect of group (F(2, 46) ¼ 3.45; p < .01), of
syllable number (p < .01 across all the syllable cat-
egories) and articulatory complexity (F(2, 46) ¼ 20;
p < .001). There was a significant interaction be-
tween group and syllable length on 3 syllables (F(2,
144) ¼ 3.4; p < .05), 4 syllables (F(2, 144) ¼ 6.8;
p < .01) and 5 syllables (F(2, 144) ¼ 9.6; p < .01),
but not 2 syllables. Specific comparisons using
t-tests revealed that the difference between the DLD
cohort and comparison groups was significant at the
.001 level for all conditions except 2 syllables. There
was no significant interaction between group and
articulatory complexity. The difference between the
DLD cohort and both comparison groups was stat-
istically significant at the .001 level for the simple
and complex nonword categories. Comparison
within each group between the simple and complex
category using t-tests revealed no significant differ-
ences. Overall, the DLD cohort had a significantly
lower overall score with a significant effect of syllable
length but a non-significant effect of articulatory
complexity. In sum, severe and significant deficits in
phonological processing and verbal short-term
memory were seen in the DLD cohort independent of
general memory ability.
Analysis of theory of mind at adult outcome
Comprehension. All three groups performed well on
the comprehension control questions for the Strange
Stories and Awkward Moments test, with non-signi-
ficant group differences identified (see Table 7). This
implied that the DLD cohort had adequate language
ability to understand the social situations presented
in the tasks.
Theory of mind. The DLD cohort had the lowest
mean scores across the three theory of mind tasks.
The MANOVA revealed a significant main effect of
group (F(6, 90) ¼ 6.6; p < .001) for theory of mind.
Between group differences were significant for the
Strange Stories task and the Awkward Moments test,
but not for the Eyes task. A composite score com-
bining the three measures show a significant im-
pairment in the DLD cohort compared with the
comparison groups (see Table 7).
Examination of the theory of mind justifications on
the Strange Stories task revealed that the DLD co-
hort gave significantly fewer correct mental state
justifications and significantly more incorrect phys-
ical state justifications than both the comparison
groups. Pearson product moment correlations were
calculated among the three theory of mind scores in
each of the 3 groups. In the DLD cohort, the Strange
Stories scores correlated significantly with scores in
both the other tests (r ¼ .63, p ¼ .006 with the Eyes
scores and r ¼ .48, p ¼ .05 with the Awkward Mo-
ments score). However the correlation between the
Eyes task and the Awkward Moments test fell short

Table 7 Theory of mind performance at the mid-thirties assessment

DLD Sibling IQM ANOVA Post hoc pairwise

Theory of mind task (n ¼ 17) (n ¼ 16) (n ¼ 17) F ratio comparisons

Eyes task (MS ¼ 25) Mean (SD) 16.6 (3.3) 18.3 (2.7) 19.4 (2.3) ns
Awkward moments
Theory of mind (MS ¼ 8) Mean (SD) 4.5 (1.5) 6.8 (2.0) 6.8 (1.0) 4.5* DLD < Sibling***
DLD < IQM**
Comprehension (MS ¼ 8) Mean (SD) 7.5 (.5) 8.0 (.0) 8.0 (.0) ns
Strange stories
Theory of mind (MS ¼ 24) Mean (SD) 16.2 (4.7) 20.3 (1.5) 21.0 (2.0) 5.7** DLD < Siblings***
DLD < IQM**
Comprehension (MS ¼ 24) Mean (SD) 19.5 (4.1) 20.7 (1.5) 21.0 (1.5) ns
Correct justifications
Mental Mean (SD) 11.3 (4.4) 17.2 (2.3) 15.1 (4.4) 9.5*** DLD < Siblings***
DLD < IQM*
Physical Mean (SD) 4.4 (2.2) 3.1 (.9) 5.5 (4.2) ns
Incorrect justifications
Mental Mean (SD) 1.9 (1.7) 1.0 (1.1) .6 (1.5) ns
Physical Mean (D) 4.0 (3.7) .7 (.9) .6 (.8) 12.1*** DLD < Siblings***
DLD < IQM***
Z-score Mean (SD) .01 (.82) 1.0 (.60) 1.1 (.33) 16.0*** DLD < Siblings**
DLD < IQM***

*p < .05; **p < .01; ***p < .001.

DLD ¼ developmental language disorder group.
IQM ¼ IQ-matched comparison group.
MS ¼ Maximum score.
Z-score ¼ Composite score of the 3 theory of mind tasks.
138 J. Clegg et al.
of statistical significance (r ¼ .29, p ¼ .3). In the
sibling group, none of the correlations reached stat-
istical significance. In the IQM group, inverse corre-
lations were found between the Strange Stories
scores and the Awkward Moments scores (r ¼ ).55;
p ¼ .02), and the Strange Stories scores and the
Eyes Task scores (r ¼ ).40; ns). The intercorrelation
between the Awkward Moments scores and the
Eyes task scores was positive but non-significant
(r ¼ .20; ns).
Psychosocial functioning
Educational provision and academic outcome. The
DLD cohort was recruited from and remained in
specialist educational provision until the age of
9 years. During this time the majority of the DLD
cohort (12, 70.1%) was educated in residential
schools for children with speech and language
impairments. The remainder were distributed within
language units attached to mainstream schools
(n ¼ 2), moderate learning disability schools (MLD)
(n ¼ 2) and mixed handicap schools (n ¼ 1). None of
the siblings had experienced any developmental
problems and were all in mainstream provision. This
difference in early educational provision was reflec-
ted in a significant group difference on early special
educational provision (v2 ¼ 22.8; df ¼ 1; p < .001).
After 9 years, the siblings all continued in main-
stream education and 11 (64.7%) DLD boys trans-
ferred into mainstream provision with very little, if
any, specialist educational support. Of the remain-
ing 6 (35.3%) DLD boys, 3 (11.7%) were in language
units attached to mainstream schools, 1 stayed in a
specialist school for speech and language disorders
and 2 remained in MLD schools. There were no sig-
nificant group differences on specialist educational
provision after 9 years.
Even though the DLD individuals transferred out
of specialist education into mainstream provision,
only 1 adult attained a CSE (Certificate of Secondary
Education; a former UK secondary school examina-
tion taken at age 16 years) level pass and 16 (94.1%)
DLD adults had never passed an examination at this
Table 8 Adult employment status and histories of the DLD cohort, siblings and NCDS cohort at the mid-thirties assessment
DLD
(n ¼ 17)
N % N %
Employed at assessment 10 58.8 15
Continually in paid employment 3 17.6 15
Two or more years unemployed 11 64.7
No paid employment ever 3 17.6
Dismissals 7 41.2
*p < .05; **p < .01; ***p < .001.
level or above. The DLD cohort had not gained any
further academic examinations or qualifications
since leaving school. In contrast to the DLD cohort,
10 (62.5%) siblings had gained five passes at O level
(Ordinary level; a former UK secondary school
examination taken at age 16 years and rated higher
than a CSE) and above. A significant difference was
reached on examinations attained (v2 ¼ 15.24;
df ¼ 1; p < .001).
Although the entire DLD cohort left secondary
education at 16 years, 9 (52.9%) individuals went on
to further education. Six individuals attended some
form of college, including 1 who completed a joinery
apprenticeship. Three (17.6%) DLD adults had
completed or were currently involved in various ba-
sic courses designed for adults with learning dis-
abilities, such as basic reading and information
technology (IT) courses. Eight (47.1%) DLD adults
did not have any form of post 16-year education
whereas 11 (68.7%) siblings did, including 7 (43.8%)
who went on to university to complete degree quali-
fications. A significant difference was identified on
completion of university or polytechnic degree
(v2 ¼ 9.44; df ¼ 1; p < .001).
Employment at adult outcome. In their early twen-
ties, 12 DLD adults were in employment, but this
had reduced to 10 by their mid-thirties (see Table 8).
Throughout adult life, the employment of the DLD
adults consisted largely of unskilled and manual
labour occupations, e.g., machine operators, council
hygiene (street cleaning) and garden technicians. In
contrast, the siblings were engaged in occupations
ranging from dentistry and accountancy to retail and
administration.
Employment histories were unstable and almost
two-thirds of the DLD adults had experienced pro-
longed periods of unemployment exceeding two
years. Three adults had never been in paid employ-
ment and, at the time of assessment, two of these
adults were in voluntary positions arranged by their
parents. One adult was helping to clean a local
church and the other was helping a family friend to
set up his local market stall.
Siblings NCDS
(n ¼ 16) (n ¼ 1384)
N % Fisher exact test
93.8 1353 95.7 DLD < Siblings (v2 ¼ 5.47*)
DLD < NCDS (v2 ¼ 51.1***)
93.8 1023 73.9 DLD < Siblings (v2 ¼ 19.25**)
DLD < NCDS (v2 ¼ 26.21***)
1 6.3 134 9.7 DLD > Siblings (v2 ¼ 19.25**)
DLD > NCDS (v2 ¼ 91.11***)
0 0 – – DLD > Siblings (v2 ¼ 15.1*)
0 0 43 3.1 DLD > Siblings (v2 ¼ 33.0***)
DLD > NCDS (v2 ¼ 35.21**)
 Cognitive, language and psychosocial outcomes of developmental language disorders 139

During the period from their early twenties to their
mid-thirties, two more adults had been dismissed
from their jobs. In all, 7 DLD adults had been dis-
missed; 2 of these had felt unable to cope with their
workload and failed to engage with their colleagues
effectively, including 1 adult who had experienced
severe bullying by his colleagues. The remaining
adults were dismissed due to inappropriate beha-
viour, including swearing at colleagues, setting office
papers on fire, fighting and a lack of punctuality.
Independent living. Independent living was another
area of difficulty for the DLD cohort (see Table 9). Of
the DLD adults not living independently, all were
reliant on parental support either in the parental
home or in supported accommodation (including a
psychiatric unit) near to the parental home. With the
exception of 1 sibling who was still in the parental
home due to being in full-time education, all of the
siblings had achieved autonomous and independent
living.
Receipt of welfare benefits and housing ten-
ure. Due to their employment difficulties, a signific-
antly higher proportion of the DLD cohort (11,
64.7%) had ever received welfare benefits compared
to one sibling (v2 ¼ 3.6; df ¼ 1; p < .01) and 131
(9.5%) members of the NCDS cohort (v2 ¼ 61.3;
df ¼ 1; p < .001). Of the 7 DLD adults living in-
dependently, all of them were living in accommoda-
tion rented from local authorities. In comparison, of
the 15 siblings living independently, 10 (62.5%) were
owner-occupiers and the remaining 5 (33.3%) were
in local authority accommodation. This was similar
to the proportion (1023, 74%) of owner-occupiers in
the NCDS cohort. Significant group differences were
identified for owner-occupation (DLD<siblings
v2 ¼ 15.24; df ¼ 1; p < .001) (DLD<NCDS v2 ¼ 47.6;
df ¼ 1; p < .001).
Relationships. Six individuals were reported to have
few acquaintances and 1 individual was described as
having an unusually extensive range of acquaint-
ances (see Table 10). This individual was reported to
visit local shop owners and market stall-holders on a
daily basis. These visits were not for the purpose of
purchasing items; instead the individual would visit
to say hello, ask how business was and then leave.
Almost half the DLD cohort was reported to have a
normal range of friendships whereas the rest were
described as having limited friendships, which
included no particular friends (see Table 10). Five
(29.41%) DLD adults reported that they were still
being teased or bullied compared to none of the
siblings (v2 ¼ 5.5; df ¼ 1; p < .05). Eight (47.05%)
individuals reported ever being teased or bullied
compared to 2 siblings; however, this did not reach
statistical significance. Examples included name
calling about appearances, behaviour and physical
aggression.
The DLD cohort had experienced significantly
fewer romantic-type relationships than both the
comparison groups (see Table 11). Of the 3 DLD
adults with children, 1 had three children, two by
his first marriage and a third by his second mar-
riage. He lived with the third child and was in
regular contact with his two other children. One
DLD adult had two children with whom he lived
and the remaining individual had one child with
whom he had very irregular contact. In their early

Table 9 Independent living in the DLD cohort and siblings at the mid-thirties assessment

DLD n ¼ 17 % Siblings n ¼ 16 % v2

Independent – away from the parental home 7 41.2 15 93.7 7.6**

Not living independently 10 58.8 1 6.3 7.6**
Independent but relies on parental support 1 5.9 0 0 Ns
Living with parents 5 29.4 1 6.3 Ns
Sheltered flat 3 17.6 0 0 Ns
Psychiatric unit 1 5.9 0 0 Ns

*p < .05; **p < .01; ***p < .001.

Table 10 Social relationships of the DLD cohort and siblings at the mid-thirties assessment

DLD n ¼ 17 Siblings n ¼ 16

N % N % v2

Acquaintances
Normal range of acquaintances 10 58.8 16 100.0 13.5***
Limited or awkward when making social contact 6 35.3 0 0 11.6**
Unusually extensive range of acquaintances 1 5.9 0 0 Ns
Friendships
Normal range of friendships 8 47.1 16 100.0 11.6**
Limited range of friendships 9 52.9 0 0 11.6**

*p < .05; **p < .01; ***p < .001.

140 J. Clegg et al.

Table 11 Relationships and family life at the mid-thirties assessment

DLD Siblings NCDS

n ¼ 17 n ¼ 16 n ¼ 1384

N % N % N % Fisher exact test

Currently living with a partner 4 23.5 11 68.7 1140 82.4 DLD < Siblings (v2 ¼ 6.8*)
DLD < NCDS (v2 ¼ 37.8***)
Ever lived as married >1 month 5 29.4 16 100.0 1255 90.7 DLD < Siblings (v2 ¼ 11.4**)
DLD < NCDS (v2 ¼ 69.1***)
Experience of a partnership breakdown 5 29.4 3 18.8 341 24.6 ns
Ever fathered a child 3 17.6 12 75.0 954 70.0 DLD < Siblings (v2 ¼ 10.9**)
DLD < NCDS (v2s ¼ 20.70***)

*p < .05; **p < .01; ***p < .001.

twenties, 4 DLD adults were married. Since then, Table 12 Schizotypal Personality Questionnaire at the mid-
two of these relationships had broken down, thirties assessment
resulting in divorce. Informant reports of these Mean SPQ DLD (n ¼ 17) Siblings (n ¼ 16)
breakdowns reported in both cases that it was subscale scores [Mean (SD)] [Mean (SD)] t
largely the result of the DLD adults finding mar-
Total 21.9 (4.5) 10.6 (4.2) 2.9**
riage difficult to cope with.
Ideas of reference 1.4 (4.5) .6 (.8) ns
Excessive social 3.4 (2.2) 1.6 (2.0) 2.7**
Adult psychiatric morbidity. The DLD cohort had a anxiety
mean score of 4.5 (SD 3.9) on the Malaise Inventory Odd beliefs or .9 (1.4) .5 (.7) ns
compared with 2.7 (SD 3.0) for the siblings and 2.03 magical thinking
Unusual perceptual .8 (.9) .5 (.7) ns
(SD 2.7) for the NCDS cohort. An ANOVA to assess
experiences
between-group differences failed to reach signific- Odd or eccentric 1.5 (1.5) .3 (.6) 2.9**
ance. A total score of 6 or more has been shown to behaviour
discriminate those with and without an interview No close friends 4.7 (2.2) 2.4 (3.0) 2.6**
diagnosis of depression (Rutter et al., 1970; Mau- Odd speech 3.8 (3.3) .6 (.8) 3.5**
Constricted affect 2.3 (2.0) .9 (1.2) 2.8**
ghan, Collishaw, & Pickles, 1999). Four (23.5%) DLD
Suspiciousness 2.3 (2.0) .6 (.7) 3.5**
adults scored above 6 compared with 1 sibling and
133 (9.6%) of the NCDS cohort. Four DLD adults *p < .05; **p < .01; ***p < .001.
(23.5%) (including 2 who scored >6 on the Malaise
Inventory) had contacted GPs or specialists for in their mid-thirties. Total SPQ scores for DLD 7
mental health-type problems compared with a lower and DLD 13 were 34 and 17 respectively. The
proportion of the NCDS cohort (198, 14.3%) Malaise score for DLD 7 was 13 and 4 for DLD 13.
(v2 ¼ 23.2; df ¼ 1; p < .05) and none of the siblings Since the early-twenties assessment, 2 more DLD
(v2 ¼ 38.0; df ¼ 1; p < .001). adults had experienced serious mental health
The DLD cohort gained higher mean scores problems. One individual (DLD 3) had been dia-
across all the 9 SPQ subscales (see Table 12). gnosed with a major depressive disorder in his late
Independent t-tests identified significant group dif- twenties (Total SPQ score of 22 and Malaise score
ferences on total score for schizotypal personality of 4). The other individual (DLD 15) had been given
disorder, excessive social anxiety, odd or eccentric the diagnosis of personality disorder in his early
behaviour, no close friends, odd speech, constricted thirties (Total SPQ score of 12 and Malaise score
affect and suspiciousness. Significant group differ- of 8).
ences were not identified for ideas of reference, odd
beliefs or magical thinking and unusual perceptual
Intercorrelations among cognitive, language and
experiences. In the DLD cohort, mean SPQ sub-
social adaptation variables in the DLD cohort
scale scores were above threshold (a positive score
of 3 or more behaviours in a subscale) for the Cognitive variables. Composite Z-scores were cal-
following three traits: excessive social anxiety, culated for language (BPVS, EOPVT and oral com-
no close friends and odd speech. The siblings did prehension task), literacy (3 subtests of the WORD),
not reach threshold on any of the SPQ traits sub- theory of mind (Eyes task, theory of mind questions
scales. from the Strange Stories and Awkward Moments
In their mid-thirties, 4 DLD adults were identified tasks) and verbal working memory (sentence repe-
with significant mental health problems. Two of tition test and the ANrep). The correlation matrix
these (DLD 7 and DLD 13) had been noted in late (see Table 13) showed significant relationships
adolescence/early twenties to have developed acute between (1) language and theory of mind and
episodes of schizophreniform disorders. These two (2) verbal working memory and literacy when the
cases had a confirmed diagnosis of schizophrenia effects of performance IQ were controlled for. When
 Cognitive, language and psychosocial outcomes of developmental language disorders 141

Table 13 Partial correlations among language, literacy, phonological processing, verbal short-term memory and theory of mind in
the DLD cohort at the mid-thirties assessment

Cognitive measure Language Literacy Phonological processing Theory of mind Sentence repetition

Literacy .55
Phonological processing .49 .36
Theory of mind .60* .40 .23
Sentence repetition .35 .70** .67** .26
Verbal working memory* .25 .59* – .27 –

*p < .05; **p < .01; ***p < .001.

*Verbal working memory ¼ a z-composite score of ANrep and Sentence repetition z-scores.

this analysis was re-run with sentence repetition

and ANrep as independent variables, a similar
pattern was identified except for the addition of a
significant correlation between literacy and sen-
tence repetition (r ¼ .70; p < .01). Interestingly, no
significant correlations were detected between lan-
guage and literacy or language and phonological
processing.
Cognitive, language and social adaptation vari-
ables. A composite score for social adaptation was
calculated using the categories of continual
employment, relationships, independent living and
friendships. Each subject was assigned a score
across these four categories. A score of 0 denoted a
poor outcome, a score of 1 a moderate outcome and a
score of 2 a good outcome (see Appendix 1 for further
details). A total score of 0 showed poor adult social
adaptation whereas a total score of 8 indicated good
social adaptation. The correlation matrix is shown in
Table 14. Social adaptation was significantly corre-
lated with language and literacy and both of the
pragmatic language impairment scores. Interest-
ingly, language was significantly correlated with
both of the pragmatic language scores and literacy
with the communicative intention rate. However,
neither of these scores was significantly correlated
with theory of mind. No significant interrelations
between social adaptation, PIQ and theory of mind
were found.
Table 14 Correlations among adult social adaptation, theory
of mind, literacy, language, performance IQ (PIQ) and prag-
matic language in the DLD cohort at the mid-thirties assess-
ment
Social Theory
Measures adaptation of mind Literacy Language
Theory of mind .40
Literacy .63* .45
Language .53* .63** .48
PIQ .21 .26 .40
Total inappropriacy .52* ).31 ).18
score
Communicative .60* ).50 ).64*
intention rate
*p < .05; **p < .01;***p < .001.
Further analysis of the cognitive and language
trajectories of the DLD cohort
The cognitive and language trajectory of the DLD
cohort warranted further analysis to identify
whether childhood language and IQ predicted
outcome in adult life. The mid-thirties receptive
language age-equivalent (AE) scores (BPVS) of the
DLD cohort were used to separate the adults into
two subgroups: a higher language outcome group
(HLO) (mean AE 13;07 years; range 13 years to
15;08 years; mean standardised score 72.0 (SD
5.7) (n ¼ 8)) and a lower language outcome group
(LLO) (mean AE 10;02 years; range 6 to 12 years;
mean standardised score 53.5 (SD 8.4) (n ¼ 9)). The
longitudinal language and cognitive profile of the
two subgroups was examined across the four time
points (see Table 15).
Performance IQ in the HLO and LLO groups was
comparable in childhood and middle childhood.
From middle childhood to the early twenties, per-
formance IQ dropped but returned to a level
approximately equivalent to that at the initial
assessment. The LLO group had a greater discrep-
ancy between verbal IQ and performance IQ
than the HLO group across the longitudinal com-
parison.
With respect to language, the HLO group had
consistently higher language scores than the LLO
group from childhood into adult life. At final out-
come, the HLO group had higher phonological pro-
cessing and theory of mind scores. Overall, higher
childhood language and literacy scores were associ-
ated with superior language and literacy in the mid-
thirties. Higher phonological processing and theory
of mind scores were associated with higher language
ability both in childhood and in adult life. The level of
intelligence and language ability obtained in child-
hood was indicative of ability later in adult life.
Further analysis of language and psychosocial
.26 outcome
).63*
The HLO group had superior levels of social adap-
).70** tation compared with the LLO group, particularly
with respect to independent living, committed rela-
tionships and history of dismissals from the
142 J. Clegg et al.

Table 15 Longitudinal cognitive and language profiles of the DLD adult language subgroups

Time 1 Time 2 Middle Time 3 Early Time 4

Cognitive domain Subgroup Childhood n ¼ 17 childhood n ¼ 9 twenties n ¼ 17 Mid-thirties n ¼ 17

Performance IQ (mean IQ quotient) HLO 90.3 (6.6) 93.7 (5.8) 80.8 (7.2) 89.8 (6.3)
LLO 88.6 (12.0) 91.2 (6.3) 77.2 (6.5) 92.4 (6.1)
Verbal IQ (mean IQ quotient) HLO 87.0 (4.3) 78.2 (6.5) 80.7 (8.4)
LLO 75.0 (10.0) 72.6 (5.8) 76.5 (7.1)
Language comprehension HLO 5:03 yrs >6 yrs 12:09 yrs 13:07 yrs
(mean AE and st. scores) z-score ¼ ).5 (1.7) st. ¼ 65.2 (9.9) st. ¼ 72.0 (5.7)
LLO 4:06 yrs >6 yrs 9:07 yrs 10:02 yrs
z-score ¼ )1.6 (2.0) st. ¼ 50.1 (8.9) st. ¼ 53.5 (5.3)
Literacy (mean AE score) HLO 84 (reading quotient) 11:05 yrs 10:02 yrs
LLO 67 (reading quotient) 10:04 yrs 9:08 yrs
Phonological processing (mean raw score) HLO 12.6 (5.8)
LLO 11.2 (5.3)
Social cognition (mean z-composite score) HLO .32 (.57)
LLO ).27 (.93)

Higher Language Outcome (HLO) (BPVS mean AE score 13:07 yrs, range 13;00 to 15;08 yrs) (n ¼ 8).
Lower Language Outcome (LLO) (BPVS mean AE score 10:02 yrs, range 6;00 to 12;00 yrs) (n ¼ 9).
AE ¼ age equivalent score.
st. ¼ standardised score.

Table 16 Adult social adaptation and psychiatric morbidity profiles of the DLD adult language subgroups at the mid-thirties
assessment

Independent Exam Ever lived as Continual Ever Dismissals Malaise SPQ

Subgroup living Ever married > 1 month employment employed Ever Score >6 total

HLO (n ¼ 8) Composite 6 0 4 2 8 2 2 19.5 (11.9)

SA (4.5, S.D. 2.8)
LLO (n ¼ 7) Composite 1 1 1 1 7 5 2 23.4 (8.2)
SA (1.7, S.D. 1.8)

Composite SA ¼ Composite social adaptation score.

Higher Language Outcome (HLO) (BPVS mean AE score 13:07 yrs, range 13;00 to 15:08 yrs) (n ¼ 8).
Lower Language Outcome (LLO) (BPVS mean AE score 10:02 yrs, range 6;00 to 12 yrs) (n ¼ 9).

workplace (see Table 16). However, the HLO group
was no more successful in maintaining employment
than the LLO group. Superior language outcome was
not associated with academic examination attain-
ment as the 1 DLD adult with a CSE-level examina-
tion pass was in the LLO group.
At the early-twenties assessment (Time 3), two
DLD adults had been diagnosed with a schizo-
phreniform illness. Both of these DLD adults were in
the LLO group. The adult with major depressive
disorder was in the LLO group and the adult with a
diagnosis of personality disorder was in the HLO
group. Total SPQ scores and individuals scoring 6 or
more on the Malaise Inventory did not differ mark-
edly across the LLO and HLO groups. The superior
cognitive outcome of the HLO group was further
associated with higher levels of social adaptation in
the HLO group with respect to independent living
and relationships but not employment or academic
attainment.
Individual outcomes
From the DLD cohort, there was 1 DLD adult (DLD 1)
who performed well across all of the measures. In his
mid-thirties he was married with two children and
had been in continuous employment since leaving
school at 16 years. DLD 1’s initial cognitive and
language profile consisted of PIQ at 91 and a recept-
ive language z-score of )1.10. In his mid-thirties
DLD 1 had a PIQ of 88 and a receptive language
standardised score of 69 (AE 13:07 years). Com-
posite theory of mind z-score was .49 and phonolo-
gical processing raw score was 18/28.
There were 2 DLD adults (DLD 16 and DLD 17)
who performed poorly across all of the measures
assessed. DLD 16 developed schizophrenia in his
early twenties and DLD 17 was receiving medical
treatment for a major depressive disorder which had
presented in his late twenties. DLD 16 and 17 had
initial PIQ scores of 80 and 75 and language z-scores
of )2.40 and )3.30 respectively. In their mid-thirties
DLD 16 had a PIQ of 76 and a receptive language
standardised score of 42. DLD 17 had a PIQ of 79
and a receptive language standardised score of 41.
Composite theory of mind score was ).46 for DLD 16
and )2.3 for DLD 17. Phonological processing
raw scores were 7/28 and 12/28 respectively.
In their mid-thirties, both adults were living in
sheltered accommodation, DLD 16 in sheltered
 Cognitive, language and psychosocial outcomes of developmental language disorders
accommodation and DLD 17 in a residential psy-
chiatric unit. Neither adult had ever been employed,
although both adults had been engaged in voluntary
work organised by their parents.
It is worth commenting on the 2 DLD adults (DLD
18 and DLD 19) who declined to participate in the
mid-thirties assessment. Contact was made with the
mother of DLD 18 who reported that he was now
divorced but in regular contact with his daughter
from his marriage and was working as a self-em-
ployed handyman. In his early twenties, DLD 18 had
a receptive language standardised score of 50 (AE
11;08 years). Contact was also made with DLD 19
but he declined to give any information about him-
self. At the early-twenties assessment, he was living
at home with his parents and working as a kitchen
porter. His receptive language standardised score at
this time was 59 (AE 11;10 years).
Discussion
Four main findings from the cognition and language
data stand out. First, the subjects who had a DLD in
childhood remained significantly impaired in their
language functioning in their mid-thirties, both in
relation to their siblings and to controls matched on
performance IQ. Second, this continuing impairment
was not restricted to ‘pure’ language skills; rather it
encompassed a wide range of cognitive skills, includ-
ing theory of mind and reading/spelling. Third, there
were moderately strong inter-correlations (mostly
circa .5) among these various cognitive skills.
Fourth, although the subgroup with the best lan-
guage outcome tended to have been somewhat less
impaired in childhood, the differences between those
with higher and lower outcomes were small.
The finding of continuing cognitive impairment is
robust with respect to the group studied in that it
was apparent in the earlier follow-up in the early
twenties and it was evident across a substantial
range of measures. Moreover, it is clear that the
subjects with DLD differed as much from their sib-
lings as they did from controls who had been
matched on performance IQ. Accordingly, it may be
concluded that the persisting impairment was a
function of the developmental language disorder,
and not of general family background. However, it is
important to note that the DLD cohort had shown
severe delays in expressive and receptive language in
childhood and the finding for those with a milder
DLD might be very different.
The psychosocial assessment of the DLD cohort in
their mid-thirties also gave rise to four main find-
ings. First, however measured, social adaptation was
substantially impaired in the DLD cohort as com-
pared with both their siblings and an IQ-matched (in
childhood) general population group. This was evid-
ent on ratings based on interviews with the subjects
themselves and on ratings from interviews with
143
informants, and it was equally striking on quantitat-
ive measures concerned with employment, inde-
pendent living, marriage and friendships. Second,
the social impairment was particularly apparent in
the field of social relationships. Third, the DLD
subjects did not show an increased rate of emotional
disturbance, at least as measured on a screening
questionnaire. On the other hand, 2 out of the 17
developed schizophreniform disorders in early adult
life and 2 developed serious mental health problems
in their early thirties (one presented with a major
depressive disorder and one showed a personality
disorder). Schizotypal traits were significantly more
common in the DLD cohort but no individual
reached the threshold of traits usually required for
the diagnosis of schizotypal disorder. Fourth, social
adaptation showed substantial correlations (in the
mid .50s) with levels of language and literacy and
with measures of pragmatic skills, although more
weakly with theory of mind skills and not with non-
verbal intelligence at all.
The cognitive profile of developmental language
disorders
The global nature of the cognitive impairment in the
mid-thirties was very striking. Thus, the DLD sub-
jects had a verbal IQ and a performance IQ some two
standard deviations below that of their siblings. The
differences with respect to reading, spelling, phono-
logical processing and theory of mind were equally
great. With a sample size of only 17, most of the in-
ter-correlations among cognitive measures fell short
of statistical significance, but most were in the .40 to
.60 range, indicating a substantial degree of overlap
in the skills they tapped. The lowest correlations
were those between theory of mind and the two tests
of verbal working memory (sentence repetition and
phonological processing), which meant that it was
possible to determine their relative prognostic
importance, relatively free of the collinearity that
affected most of the other measures. Nevertheless,
the weak correlation between verbal working mem-
ory and theory of mind (r ¼ .27) means that their
relative prognostic importance is probably valid. By
contrast, the high inter-correlation between phono-
logical processing and sentence repetition (r ¼ .67)
means that the lack of effect of phonological pro-
cessing once sentence repetition was taken into
account probably does not mean much.
The developmental trajectory of cognition
in developmental language disorders
From childhood into adult life, IQ was in the normal
range, with a consistent discrepancy between per-
formance and verbal IQ. The drop in performance IQ
identified between middle childhood and early adult
life proved to be temporary, and PIQ returned to a
level equivalent to that in childhood. The reasons for
144 J. Clegg et al.
the temporary drop are unclear. Explanations are
complicated by the changes in IQ assessments,
missing data for 9 DLD subjects at middle childhood
and also the possibility of practice effects (Rabbitt,
Diggle, Smith, Holland, & McInnes, 2001) using the
WAIS-R at both early twenties and mid-thirties. Two
other follow-up studies of children with language
impairments have also identified decreasing levels of
IQ over time. Tomblin et al. (1992) reported a decline
in IQ in the adults used in a pedigree analysis study.
Conti-Ramsden et al. (2001b) found a drop in PIQ in
children with SLI from 7 to 11 years.
Of particular interest was the plateau reached in
early adult life, after which no further improvement
was gained, with the eventual language outcome at a
level approximately equivalent to 11 years of age.
The developmental trajectory showed that the initial
language impairment was not a result of a matura-
tional lag, confirming the initial diagnosis of a dis-
order rather than just a delay in language
development. What remains uncertain is the extent
to which this plateau was an inevitable consequence
of the intrinsic disorder and the extent to which it
could be ameliorated through appropriate interven-
tion. It is noteworthy that the plateau developed at
approximately the same time as most of the subjects
moved from specialist education to mainstream
schooling (Howlin et al., 2000). At the very least the
findings call out for greater attention to the chil-
dren’s need at that point in their development.
The role of phonological processing in persisting
developmental language disorders
The significant phonological processing deficit iden-
tified in the DLD adults supports the hypothesised
developmental link between language impairment
and phonological processing (Bishop et al., 1996;
Gathercole & Baddeley, 1993, 1990; Stothard et al.,
1998). However, the cognitive profile of the DLD
adults does question the specific causal role of the
phonological processing deficit with respect to lan-
guage development. The deficit in phonological pro-
cessing co-occurred with a deficit in sentence
repetition, neither of which was attributable to a
general impairment in visual and verbal recall and
recognition. However, the effect size for phonological
processing was larger than for any of the other
measures. The results fail to support the causal role
of phonological processing with respect to language
but do confirm that it is a sensitive marker of DLD. In
this DLD cohort phonological processing seems to be
an associated rather than a causal deficit.
The role of social cognition in the language
outcomes of developmental language disorders
The identification of a social cognition deficit not
attributable to low intelligence but associated with
severe language disorder in adult life raises several
important issues regarding the theory of mind con-
struct and its relationship to language. Firstly, hav-
ing a theory of mind deficit cannot presuppose a
diagnosis of autism. The DLD cohort was not iden-
tified as autistic in childhood or on any of the three
follow-ups. The nature of their social impairments in
adult life cannot be attributed to autistic spectrum
disorder inferred from a theory of mind deficit. It is
argued from a clinical viewpoint that the cognitive
profile associated with DLD (Briscoe et al., 2001;
Conti-Ramsden et al., 2000; Stothard et al., 1998) is
not the same as that found in autistic spectrum
disorders. However, evidence to support this is lim-
ited. In fact, Kjelgaard and Tager-Flusberg (2001)
reported that verbally able children with autism had
a similar language profile to the phenotype of SLI.
The phenotype is defined by non-word repetition
deficits and superior vocabulary to grammatical
abilities (Tager-Flusberg & Cooper, 1999). Language
is a complex task and constitutes a much broader
range of abilities than grammar and non-word re-
petition. It would have been interesting to know
whether these verbally able children with autism
were able to pass second-order theory of mind tasks.
The theory of mind deficit found in DLD also cannot
entirely be accounted for by the impaired language
skills. In adult life, the DLD adults had an approx-
imate language level equivalent to 10 to 11 years.
Such a language level is considered more than ade-
quate to pass theory of mind tasks (Happé, 1994;
Hughes et al., 2000). Perhaps the semantic-prag-
matic and syntactic demands of the Strange Stories
and Awkward Moments tasks were too complex but
this would need to be analysed and confirmed. Nev-
ertheless, there may be difficulties in measuring
theory of mind as an independent construct in DLD.
The cognitive profile of the DLD adults included
deficits in phonological processing, verbal IQ, and
sentence repetition that may have affected perform-
ance on the theory of mind tasks. None of these
cognitive impairments were identified in the com-
parison groups, all of whom had a much superior
theory of mind performance.
The lack of significant positive correlations among
the theory of mind tasks in both comparison groups,
but not in the DLD cohort, was surprising. Non-sig-
nificant correlations between the Awkward Moments
test and the Strange Stories test were also found in
high functioning autism (Heavey et al., 2000). The
three tasks differed in task format and therefore the
level of non-specific task demands may have affected
the correlation. The validity of theory of mind tasks
in normally developing and developmentally delayed
children has been questioned (Charman & Camp-
bell, 1997; Mayes, Klin, Tercyak, Cicchetti, & Cohen,
1996). However, although Hughes et al. (2000) found
good agreement across theory of mind tasks in a
cohort of typically developing 5-year-old children,
the consistency across tasks has yet to be replicated
in adult populations.
 Cognitive, language and psychosocial outcomes of developmental language disorders
The nature of the psychosocial impairment in DLD
The breadth of social difficulties still evident in the
mid-thirties was very striking. Employment con-
stituted a major area of difficulty where only 3 DLD
adults had successfully held down jobs since leaving
school at 16 years. Only two-fifths of the DLD adults
were living independently, as compared with nearly
all of their siblings. Social services had undertaken
the accommodation needs of only a small proportion
of the DLD adults, and ageing parents were still
playing a significant role in the day-to-day welfare of
their sons, placing considerable financial and emo-
tional burdens on these parents.
Approximately half of the DLD adults had sus-
tained problems in establishing relationships, across
acquaintances, friendships and sexual relation-
ships. The difficulty of establishing social networks
and integrating with society resulted in socially
restricted lives which affected opportunities for
employment and independent living. This then
resulted in poorer living circumstances and material
conditions, reflected by higher receipt of welfare
benefits and a paucity of owner-occupier accom-
modation. The fact that this social maladaptation
was not apparent in the siblings indicated that it was
a function of the language disorder rather than
family background. For measures that were
available for the NCDS cohort, the siblings showed
social functioning that was characteristic of the
general population, whereas that was not so at all for
the DLD cohort.
The Malaise Inventory failed to identify significant
levels of affective symptomatology in the DLD cohort.
Surprisingly, the lack of employment, difficulties in
establishing relationships and decreased social
opportunities did not appear to predispose the co-
hort to affective disorders. The Malaise Inventory
may not have been specific enough to identify such
behaviours and perhaps in-depth psychiatric inter-
views would have shown more psychopathology.
The DLD cohort had a higher rate of schizotypal
traits as measured by the SPQ, with three traits
(excessive social anxiety, no close friends and odd
speech) above threshold levels; these traits seemed
to be linked more to their difficulties in social adap-
tation and the language disorder rather than to
features of schizophrenia.
Comparison of the developmental histories of the
four adults with psychiatric disorder, although
interesting, was inconclusive. Two of the adults were
reported to have quasi-obsessive behaviours in
childhood (Bartak et al., 1975). This was associated
with schizophrenia in one adult and with depression
in the other. The trajectory of the adults with schizo-
phrenia showed that one had particularly low levels
of IQ and language but these were much superior in
the other adult. Specific patterns of IQ, language and
social/behavioural difficulties could not be related to
145
the psychiatric disorders. The common feature was
the developmental language disorder.
Explaining impaired adult social adaptation in
persisting developmental language disorders
In considering the possible reasons for the sub-
stantial social impairment shown by most DLD
subjects, four main alternatives present themselves.
First, it could be that it is an intrinsic part of severe
DLD involving deficits in receptive as well as
expressive language. In support of that suggestion
are the substantial correlations between language
skills and social adaptation. However, there was no
association between performance IQ and social
adaptation, and the associations between language
in adult life and social adaptation were stronger
than the comparable association with language in
childhood (Bartak et al., 1975). Second, the poor
social functioning could be a consequence of the
degree to which the language deficit persisted. The
comparison between the higher and lower language
outcome groups suggested that this was the case
with respect to independent living, but it was not so
for employment, and even with those subjects with
the greatest language skills, there were often deficits
in love relationships and in close confiding friend-
ships.
Third, the social deficits in adult life could be a
consequence, not of overall language skills, but ra-
ther of either pragmatic deficits or theory of mind
impairment. There were significant correlations (.52
to .60) between the two measures of pragmatic lan-
guage (as obtained in the early twenties) and social
adaptation in the mid-thirties. The correlation be-
tween theory of mind skills and social adaptation
(.40) was lower and fell short of statistical signific-
ance. It could be suggested, therefore, that prag-
matic deficits played a role in the social impairment,
but that was less plausible in the case of theory of
mind. As a consequence, no firm conclusions are
possible on the role of specific cognitive deficits in
the persisting social impairment. However, the evid-
ence suggests the value of further study of pragmatic
deficits.
Fourth, the social problems in adult life could, at
least in part, reflect limitations in educational pro-
vision. Considering the complex cognitive profile of
the DLD cohort, their educational needs were not
well catered for at secondary school level, even
though at primary level they attended the best spe-
cial schools for language disorders. Their poor aca-
demic outcome suggests that the lack of specialist
educational provision may have had a detrimental
effect on their academic potential. The majority was
mainstreamed at secondary school level and the
remainder catered for by MLD schools and schools
for children with mental and physical handicaps,
even though their intelligence was continuously
146 J. Clegg et al.
assessed to be within the normal range. At this 36-
year follow-up, the average reading level was only
about 9 years, which stood in great contrast to the
scholastic success of their siblings. The failure of the
majority of the DLD adults to obtain any formal
qualifications on leaving school is likely to have
affected their employment prospects, which subse-
quently limited social opportunities, increased
isolation and reduced quality of life.
Clinical implications
The withdrawal of specialist educational support
and services from about 9 years onwards assumed
that the language, literacy and educational needs
present in childhood would simply resolve, pre-
supposing that these children would reach a level of
functioning that would equip them for the demands
of adult life. Yet, the psychosocial consequences of
DLD were perceived by families to be more pervas-
ive in adult life when no services were available
than in childhood when services were available.
Anecdotally, parents were often baffled by how
socially impaired their son was compared to their
sibling(s). This was particularly heightened as par-
ents felt they had no tangible cause to explain their
sons’ difficulties due to the lack of information,
services and support they had received. Current
provision for children with DLD is much more
understanding of the needs of these children and in
some regions specialist provision does now extend
into secondary school age.
There needs to be an increased awareness of the
persisting social difficulties that individuals with
DLD may go on to experience. The normal perform-
ance IQ of the DLD cohort prevented access to adult
learning disability services. To a certain extent, they
slipped through the remit of secondary educational
and social services provision. Speech and language
therapy plays an important role in the provision for
children with DLD but this generally diminishes the
older children become. The needs of this group are
complex and multidisciplinary support is required as
they enter adolescence and adult life, particularly
with respect to academic progress and improving
social competence.
Acknowledgements
This work was funded by an NHS Research and
Development grant (ref: PCD2/A3/263). Martin
Eales generously provided the individualised data on
pragmatics and we are also indebted to Stephan
Collishaw and Barbara Maughan for analyses of the
NCDS data. We are most grateful to the families for
their generous cooperation with the extensive inter-
viewing and psychological assessments that the
study entailed.
Correspondence to
Judy Clegg, Human Communication Sciences, Uni-
versity of Sheffield, 31 Claremont Crescent, Sheffield
S10 2TA, UK; Tel: 0114 2222450; Fax: 0114 273
0547; Email: j.clegg@sheffield.ac.uk
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 Cognitive, language and psychosocial outcomes of developmental language disorders 149

Appendix 1: Social adaptation composite ratings

Continual employment
Good (2): In employment since leaving school with no periods of two or more years of unemployment
Moderate (1): Periods of employment but experienced periods of unemployment of two or more years
Poor (0): No experience of paid employment ever

Relationships
Good (2): Ever lived as married or in cohabiting relationship for one month or more
Moderate (1): Experience of a committed relationship
Poor (0): No experience of a committed relationship

Friendships
Good (2): Normal range of friendships, defined as: one or more friends of roughly own age with whom shares a
variety of interests and social activities
Moderate (1): Limited range of friendships, defined as: little spontaneous and/or stereotype socialising within
arranged social groups and non-reciprocal relationships
Poor (0): No friendships of any type reported

Independent living
Good (2): Living entirely independently – no support needed
Moderate (1): Living independently with limited support
Poor (0): Living in the parental home or in supported accommodation