In ADHD, Language Falters Most in Pragmatics

What the research found

Children with ADHD outperformed children with developmental language disorder on vocabulary, grammar and sentence structure in the studies that compared the two groups directly. Where their language fell short of typically developing peers was in conversation and in the telling of a story.

That is the general conclusion of a systematic review by Inmaculada Méndez-Freije, Débora Areces and Celestino Rodríguez at the University of Oviedo, published in the journal Children in December 2023. Searching Scopus, Web of Science and PsycINFO, they retrieved 260 papers and retained fifteen empirical studies from 2013 to 2023 that measured language in children with ADHD, with developmental language disorder, or with both.

Developmental language disorder is the current term for persistent difficulty acquiring and using language where no other cause accounts for it. The review sorts its findings by domain: phonology, the sound system; morphosyntax, the forms of words and the structure of sentences; semantics, meaning and vocabulary; and pragmatics, the use of language with another person, which covers turn-taking, staying on topic, and giving a listener what they need.

A Greek sample of 29 children with ADHD, 25 with developmental language disorder and 29 developing typically, aged four to eight, placed structural language in the ADHD group significantly below the typically developing children and significantly above the group with the language disorder. That same ADHD group scored lower on pragmatics than every other group, though the difference did not reach statistical significance.

A Spanish comparison of 48 children with ADHD, 47 with developmental language disorder and 47 typically developing, aged seven to twelve, found significant differences among the three groups in semantics and in pragmatics. Semantics was less affected in the ADHD group than in the language disorder group, while its pragmatic scores were the lowest of the three.

Staikova and colleagues, working with 28 American children with ADHD and 35 typically developing peers aged seven to eleven, found the ADHD group poorer on every pragmatic measure administered, and the gap persisted after general language ability was statistically controlled. In Brazil, 20 children with ADHD told stories of lower coherence than 20 typically developing peers.

The literature does not speak with one voice. A Norwegian comparison of 21 children with ADHD, 19 with developmental language disorder and 19 typically developing rated communication difficulty as severe in the ADHD group as in the language disorder group, with the two equally impaired on semantics. The review calls its own evidence base heterogeneous, with samples running from five children to 370 and only two of the fifteen studies including children who carried both diagnoses. What survived the disagreement was the location of the trouble in ADHD: pragmatics and narrative coherence, the parts of language that appear only when someone else is listening.

What it means for you and your child

A child who interrupts, who loses the thread halfway through an account of the afternoon, or who answers a question adjacent to the one asked, is usually described in the vocabulary of behaviour. The same performance is measurable as language, and in these studies it was measured that way.

No study within the review asked whether such difficulties are commonly misattributed, so the fifteen establish something narrower: pragmatic language and narrative coherence are testable domains, distinct from vocabulary and grammar, and in ADHD samples they are where the scores drop.

Performance in one domain predicted little about the other. Both the Spanish and the Greek comparisons found semantics comparatively preserved in their ADHD groups alongside the lowest pragmatic scores in the study. A Swiss study of twenty eight-year-olds per group concluded that difficulty with morphosyntax is not characteristic of ADHD, while noting that children with ADHD can perform on those tasks in a way that resembles impairment. A single test, chosen for convenience, can produce a misleading profile in either direction.

Who reaches a speech and language therapist at all is uneven. The review reports the consistent finding that boys are more likely than girls to experience language delay and to receive therapy services, and more likely to be diagnosed with ADHD, and it attributes part of the gap to gender stereotypes.

A referral for speech and language assessment is answered with whatever instruments the clinician selects, and the domains covered follow from what the request names. The review is direct about the absence of any single standardised tool spanning all domains of language, which makes the choice of instrument consequential. Vocabulary and grammar are captured well by the tests in common use. Pragmatic language and narrative require their own.

Pragmatic assessment carries a weakness the authors state plainly, since a standardised test administered in a quiet room may not represent how a child communicates in the noise of a classroom. Observation across settings belongs alongside those scores rather than behind them, and a description of what conversation actually looks like at home gives the clinician something the test cannot supply.

The most useful request names the domain, asking for pragmatic language and narrative to be assessed alongside vocabulary and grammar. Naming the domain is what turns a referral into an answerable question.