Childhood Maltreatment Consequences On Social Pragmatic Communication. A Systematic Review of The Literature

PERSPECTIVES SIG 1
Review Article
Childhood Maltreatment Consequences

on Social Pragmatic Communication:
A Systematic Review of the Literature
Yvette D. Hytera
Purpose: Maltreatment is a threat to child health and well- and that their method and findings were based on an
being and negatively influences all aspects of development, experimental study. Studies were excluded if they were
including language. Less seems to be known about the written in a language other than English, focused on adults,
consequences that maltreatment has on social pragmatic did not include the social pragmatic communication and
communication. A systematic review of the literature was maltreatment concepts, were a systematic review or meta-
performed to summarize existing empirical research on analysis, or were a theoretical rather than experimental study.
complex trauma (the impact of maltreatment, including abuse A modified version of the Primary Research Appraisal Tool
and neglect, in the caregiving system) on social pragmatic was used to determine key characteristics of each article.
communication of children and youth. The goal of this Results: Thirty-eight articles met inclusion criteria for this
review article was to review the empirical evidence of the study. Findings of these studies provide evidence that
association between maltreatment and social pragmatic maltreatment has an impact on social pragmatic communication
communication profiles of children. including social cognition, perspective taking, and belief
Method: Research articles published between 1974, when attribution; executive functions including working memory;
the first comprehensive law of child protection was enacted, and pragmatic language including narrative discourse and
and 2020 were reviewed. Seven electronic databases were the use of varied communicative functions.
used to conduct the search for literature using several Conclusions: The major findings have implications for
combined concepts related to social pragmatic communication knowledge and skills of speech-language and hearing
and maltreatment. The inclusion criteria were that articles professionals working with children and adolescents and for
addressed any form of maltreatment, included participants the type of assessment and intervention processes used to
aged 18 years or younger, and primarily focused on the assess social pragmatic communication. Suggestions for
impact of maltreatment on social pragmatic communication future studies are provided.
O
ne of the major health issues facing children around Yehuda, 2016). Maltreatment is associated with an increased
the world is maltreatment. Maltreatment is one risk of health problems throughout life, as it disrupts the
type of adverse childhood experience (Burke-Harris, body’s regulatory systems and brain development (Basu
2018). The different forms of maltreatment are abuse (physi- et al., 2017; Yehuda, 2016). The impact of maltreatment
cal, sexual, and emotional injury) and neglect. Maltreatment is pervasive, affecting neurological, cognitive, and develop-
that takes place in the caregiving system (family/extended mental functioning (Richardson et al., 2015).
family) and the life-long effects are called complex trauma In a report published by the U.S. Department of
(Cook et al., 2003; Wamser-Nanney & Vandenberg, 2013; Health and Human Services (2018), it was stated that the
rate of substantiated child maltreatment has fluctuated
within a particular range over the last 5 years, with 675,000
a child victims in 2014 and a total of 678,000 victims in 2018
Department of Speech, Language and Hearing Sciences, Western
Michigan University, Kalamazoo
(generally, a rate of 9.2 per 1,000 children). Globally, the
numbers are more severe, with three out of four children
Correspondence to Yvette D. Hyter: yvette.hyter@wmich.edu
experiencing some sort of maltreatment within the caregiv-
Editor-in-Chief: Brenda L. Beverly
ing system (World Health Organization, 2020). Children
Editor: Laura B. Green
3 years old and younger experience maltreatment at a higher
Received September 2, 2020
rate than older children, as do children with disabilities,
Revision received December 14, 2020
Accepted February 2, 2021
https://doi.org/10.1044/2021_PERSP-20-00222 Disclosures
Publisher Note: This article is part of the Forum: Child Traumatic Financial: Yvette D. Hyter has no relevant financial interests to disclose.
Stress and Language. Nonfinancial: Yvette D. Hyter has no relevant nonfinancial interests to disclose.
262 Perspectives of the ASHA Special Interest Groups • Vol. 6 • 262–287 • April 2021 • Copyright © 2021 American Speech-Language-Hearing Association
Downloaded from: https://pubs.asha.org 142.116.85.78 on 06/28/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions

SIG 1 Language Learning and Education
including communication disabilities (Westby, 2007). Also, (Zimmerman et al., 1979) and Index of Productive Syntax
it is likely that some children who experience maltreatment (Scarborough, 1990). This group of children also showed
are exposed to multiple types of maltreatment at any given low receptive language, as measured by such tests as the
time. Ciolino (2018) and Ciolino et al. (2020) report in their Test for Auditory Comprehension of Language (Carrow-
data that, on average, participants in their studies experi- Woolfolk, 1985) and the Miller–Yoder Language Compre-
enced eight traumatic events including, but not limited to, hension Test (Miller & Yoder, 1984). Finally, receptive
physical abuse, neglect, emotional abuse, sexual abuse, and vocabulary knowledge (as measured by the Peabody Pic-
exposure to domestic violence. ture Vocabulary Test–Revised; Dunn et al., 1981) was
Data on child victims of maltreatment often show found to be lower than peers without maltreatment histories
disproportional representation by children and families of from similar socioeconomic backgrounds.
color. For example, Alaskan children are 0.9% of the U.S. Sylvestre et al. (2016) reviewed 21 studies, with a
population but represent 1.3% of the victims of maltreat- total of 1,420 participants (721 children with histories of
ment. Similarly, African American children, who are 13.8% maltreatment and 699 controls). Sylvestre et al. found
of the population, represent 22.6% of the victims (Child that receptive language included measures that focused
Welfare Information Gateway, 2016). On the other hand, on auditory comprehension or comprehension of direc-
whites1 are 52% of the population but represent 46% of tions (p. 50), expressive language included mean length
the children in the child welfare system (Child Welfare In- of utterance or speed of naming objects, and pragmatics
formation Gateway, 2016). It is difficult to know if dispro- was composed of conversational discourse. They found that,
portional representations are true differences or if they are regardless of the language variable, children with histories
due to structural racism2 in the child welfare system. There of maltreatment performed more poorly on language mea-
are also differences reported between girls and boys. While sures than their peers without histories of maltreatment.
they experience abuse at the same rate, girls are more likely Also, they found that the language abilities of younger chil-
to experience sexual abuse, and boys are more likely to dren were more negatively affected by maltreatment than
experience physical abuse (Asscher et al., 2015). Boys are the language of older children. In other words, “early devel-
killed by their abusers at higher rates than girls (Centers for opment is particularly vulnerable to abuse and/or neglect”
Disease Control and Prevention, 2014). (p. 54). Both the Lum et al. (2015) and Sylvestre et al. meta-
An emerging body of literature exists about the rela- analyses confirmed what previous authors have reported—
tionship among language and maltreatment. We know that that the language skills, regardless of language variable,
children with histories of maltreatment have more language of children with histories of maltreatment are less well
concerns than their peers who have not experienced mal- developed than those of their peers without histories of
treatment. In two meta-analyses (Lum et al., 2015; Sylvestre maltreatment.
et al., 2016), a total of 47 publications were reviewed, which Lum et al. (2015) did not include a specific focus on
examined the language abilities of a total of 1,897 children pragmatics—the use of language effectively in social situa-
with histories of maltreatment compared to 1,635 peers with- tions with different interlocutors. Although 16 (76%) of the
out a maltreatment history. Language in these meta-analyses 21 articles reviewed by Sylvestre et al. (2016) focused on
was defined as vocabulary and the comprehension and pro- pragmatics, the only pragmatic variable included was con-
duction of language in the case of Lum et al. (2015) and re- versational discourse. Pragmatics plays an important role
ceptive language, expressive language, and pragmatics in the in social communication, which is essential for social–
case of Sylvestre et al. (2016). emotional development and well-being, prosocial behaviors,
Lum et al. (2015) reviewed 26 studies, with a total of as well as positive peer interactions and academic outcomes.
1,176 children participants who had histories of maltreat- Less literature, however, exists about the consequences of
ment and 936 controls. They found that children with his- maltreatment on social pragmatic communication. We al-
tories of maltreatment consistently had lower language ready know that conversational discourse is negatively
abilities, although it must be noted that not all of the 1,176 affected by maltreatment experiences (Sylvestre et al.,
children were assessed with the same language measures. 2016), but we do not know whether maltreatment modifies
Specifically, children with histories of maltreatment showed all pragmatic skills (discourse management, communicative
less effective expressive language as measured by language functions, and presupposition) equally. We have evidence
samples and scores from the Preschool Language Scale that there are higher rates of cognitive difficulties among
children with maltreatment histories (Yehuda, 2016), that
younger children (toddlers) have higher levels of language
1
I am using guidelines of the diversity style guide by not capitalizing delays (Sylvestre & Mérette, 2010), and that some authors
“white.” See Diversity Style Guide at https://www.diversitystyleguide. found vocabulary production to be negatively affected by
com.
2 a trauma/maltreatment history (Hyter, 2012; Richardson
Structural racism is part of the social structures (economic, political,
and cultural systems) in which we exist. It happens when public
et al., 2015; Viezel et al., 2015). We do not have sufficient
policies, daily practices within an institution, and historical cultural information, however, about how social communication—
representations reinforce privilege for groups who identify as white the intersection of cognition, language, and pragmatics—is
and inequity for groups who identify as people of color (Hyter, 2014; affected by maltreatment history. The purpose of this sys-
Hyter & Salas-Provance, 2019; Powell, 2008). tematic review is to summarize the literature on the impact
Hyter: Childhood Maltreatment Social Pragmatic Comm 263

of maltreatment history on pragmatic language and social function (McCloskey et al., 2009) that contributes to the
communication of children and youth. ability to form relationships among multiple ideas (Diamond,
2013), and in this conceptual model, it adheres all compo-
nents of social pragmatic communication together (Hyter,
Social Pragmatic Communication 2017).
Social pragmatic communication is the ability to make Social pragmatic communication is important for
sense of social situations and then behave in ways that are school readiness and academic success. It supports the abil-
consistent with and effective for communicating in those ity to make sense of social situations and others’ perspec-
contexts. Social pragmatic communication is influenced tives and motivations, which will help a person manage
by culture because it is through culture that one learns how their own behavior and language and understand and pre-
to interpret the contexts in which one engages and meaning dict the behaviors of others. These skills are important in es-
of interactions (Dejarnette et al., 2015; Huang, 2017; Hyter, tablishing and maintaining relationships with others. Social
2007, 2017). pragmatic communication can also facilitate a child’s access
Hyter and Sloane (2013) strengthened Hyter’s (2012) to the academic curriculum by helping them (a) express ba-
model of social pragmatic communication as the inter- sic needs/ideas, (b) know when someone is not listening to
section among social cognition, cognition, and pragmatic them, (c) read communicative cues such as knowing when
language (see Figure 1). These skills allow one to see events someone is finished talking, (d) use reciprocal conversation
from others’ perspectives (e.g., perspective taking); determine patterns, (e) understand that one’s peers are learning and
others’ goals (e.g., intention reading); recognize that others attending to the same thing but that they may have a differ-
have different beliefs, feelings, and needs (e.g., theory of ent perspective about what is being learned, and (f ) main-
mind); use cognitive flexibility to adapt to diverse commu- tain emotional regulation in stressful times (Garcia-Winner,
nicative contexts and partners (e.g., executive functions or 2015, 2016).
cognitive skills that allow a person to self-regulate, inhibit The purpose of this systematic review was to summa-
behaviors, and engage in goal directed acts); and effectively rize existing research on the impact of complex trauma on
carry out communicative goals during various interactions social pragmatic communication of children and youth. Exist-
(e.g., pragmatic language). These skills are all accomplished ing publications were reviewed for evidence of the rela-
while also holding on to and processing information from tionship between maltreatment in all of its forms and the
various sources (e.g., working memory; Hyter & Sloane, variables of social pragmatic communication.
2013). In this conceptualization of social pragmatic commu-
nication, executive functions are mediated by emotional and
self-regulation and vice versa. Social cognition and executive Method
functions (inhibition, shifting) are foundational supports This systematic review was designed to summarize
for social communication (Hyter & Sloane, 2013; Maughan published studies between January 1974 (the year that the
& Cicchetti, 2002). Working memory is also an executive Child Abuse Prevention and Treatment Act [1974], Public Law
93-247, was first passed in the United States) and February
Figure 1. Hyter and Sloane’s (2013) model of social communication 2020 that provided empirical evidence of the social prag-
(printed with permission from the American Speech-Language- matic communication abilities of children and youth with a
Hearing Association and Springer Nature). history of maltreatment. Table 1 shows the seven databases
(CINAHL, EbscoHost, ERIC, PsycINFO, PubMed, Scopus,
and Social Sciences Citation Index) used for this study and
the number of titles within each database.
Inclusion Criteria and Study Selection

The aforementioned databases were searched for ar-
ticles published between 1974 and February 2020 with the
following concepts in combination: maltreatment, complex
trauma, abuse, neglect, pragmatics, language use in social
situations, social communication, communication functions,
speech acts, discourse, conversation, conversational dis-
course, expository text, narrative discourse, social cognition,
belief attribution, theory of mind, executive functions, affect
regulation, emotional regulation, and working memory.
Table 2 shows how the concepts above were combined. Ref-
erences of articles that met inclusionary criteria were also
reviewed for additional published studies.
Articles included in this study were initially reviewed
for inclusion via a five-step process that was composed of
264 Perspectives of the ASHA Special Interest Groups • Vol. 6 • 262–287 • April 2021

Table 1. Databases used to conduct the search for literature on the effects of maltreatment on the social pragmatic communication of children
and youth.
Name Description Database holdings
CINAHL Includes nursing journals and related fields 1,300 journals from 1954 to the present
EbscoHost Electronic books Over 25,000 electronic books
ERIC (ProQuest) Index in education Over 2,000 journals
More than 450,000 reports in education and related
fields from 1966 to the present
PsycINFO Literature in psychology from around the world and More than 2,285 journals
related disciplines Dated from 1806 to the present
Includes journal articles, technical reports, books,
book chapters, and dissertations
PubMed National library of medicine and is used to search Content from 30,000 journalsa
MEDLINE From 1893 to the present
Index to medical research
Scopus Literature from natural and social sciences Content from 24,600 journals and 5,000 publishersb
from 1970 to the present
Social Sciences Multidisciplinary database More than 1,725 journals across 50 disciplines with
Citation Index coverage from 1899 to the present
Note. Information retrieved from the following citations: Elsevier (2020), NIH National Library of Medicine (2018), and Western Michigan
University’s Libraries Databases (n.d.).
a
NIH National Library of Medicine (2018). bElsevier (2020).
(a) screening by reading the title and determining if any of 1. they addressed maltreatment, abuse, neglect, and/or
the search terms were in the title; (b) assigning a code num- complex trauma;
ber (e.g., 20-001) to the articles that passed the title screen- 2. they included participants who were younger than
ing; (c) reading the abstract to determine if the article met 18 years of age;
criteria for inclusion in the study; (d) removing duplicate arti-
cles and articles that did not meet criteria for inclusion in the 3. they had primary aims focused on examining the im-
study, for example, those articles about brain injury (i.e., trau- pact of maltreatment, abuse, neglect, and/or complex
matic brain injury) or that focused on adults rather than chil- trauma on social pragmatic communication as listed
dren; and (e) summarizing the articles that met criteria for in Table 2;
inclusion using a variation of the Primary Research Appraisal 4. their methodology and findings were based on empiri-
Tool (PRAT; DeJarnette et al., 2012; Hyter et al., 2015). cal evidence; and
Studies were excluded if they focused on adults (or 5. they were written in English.
teens older than 18 years), did not include social pragmatic
communication concepts as a dependent variable, or were The quality assessment of the articles was conducting
a systematic review or meta-analysis. Articles were included using a modified version of the PRAT in the Appendix
if they met the following criteria: (DeJarnette et al., 2012; Hyter et al., 2015). The PRAT
Table 2. Search terms and combinations.
One of these terms (maltreatment, complex trauma, abuse, and neglect) were searched in Pragmatics
combination with each of the terms in the next column. Language use in social situations
Social communication
Communication functions
Speech acts
Discourse
Conversation
Conversational discourse
Expository discourse/expository text
Narrative discourse
Social cognition
Belief attribution
Theory of mind
Executive functions
Affect regulation
Emotional regulation
Working memory

was used to denote whether or not the articles included These 38 studies included a total of 4,856 children
the following key characteristics: with histories of various forms of maltreatment and 2,563
children without maltreatment histories. Twenty-eight (74%)
1. clear identification of the research purpose and/or re-
of the 38 studies included a control group and reported on
search questions—clear identification of theoretical
the gender of participants (n = 37, 97.4%), as well as pro-
framework and/or hypotheses that guided the study;
vided information on the participants’ race/ethnicity (n = 24,
2. a research methodology that included number of par- 63.1%) and socioeconomic status (SES; n = 29, 76.3%).
ticipants and participant demographics, including Only two studies included all male participants (Mezzacappa,
racial/ethnic, gender and socioeconomic composi- 2001; Zou et al., 2013), one indicating that their sample of
tions, and type of trauma history—whether participant female participants was so small (n = 10) that they elected
attrition was discussed and whether there were similari- to not include them in that study.
ties among the groups (study group and control group) Table 3 shows that sample sizes ranged from seven
or participants; (Katz, 2013) to 1,554 participants (Bernardes et al., 2020)
3. a research design that included a comparison group and from children ages 12;7 (years;months; Demeusy et al.,
or a control group with randomization—whether 2018) up to 18 years (Moreno-Manso et al., 2010). Race/
measures were valid and reliable instruments; and ethnicity of participants were diverse. Although 14 (37%)
4. a discussion of primary results and the implications studies did not report race/ethnicity of participants, only one
of those findings were reported. indicated that authors were prohibited from doing so due
to ethical requirements (Katz et al., 2016). SES was often
determined based on whether or not families of participants
Results were receiving federal or state aid/assistance or on the
Hollingshead Four Factor Index (Hollingshead, 2011). Addi-
Demographics of Articles Included
tional measures for determining SES included geographical
in This Systematic Review regions where families of participants lived, educational
Figure 2 shows a diagram of studies used in this sys- level of parents/caregivers, and household income. Some
temic review. A total of 533 articles were initially identified that did not report SES indicated that participants were
through the search of electronic databases. After screening matched on SES, although specific SES was not included
the title and abstract and reviewing the bibliographies of ar- in descriptions of participant demographics.
ticles that met inclusion criteria, 38 studies comprised data The types of maltreatment to which study participants
for this review. Although this literature search spanned years were exposed were varied and included emotional mistreat-
from 1974 to the present, the majority (n = 23, 61%) of the ment, physical abuse (e.g., beating, choking), sexual abuse,
38 studies that met inclusion criteria were published between neglect, familial rejection, separation from parents, witnes-
2010 and 2019, suggesting that this topic is of concern and sing violence, witnessing domestic violence (e.g., spousal
relevant for our current context. Of the 38 articles that met violence), exposure to family violence, and surviving attempted
inclusion criteria for this study, two (5%) were published filicide. Nine social pragmatic communication domains
in the 1980s, four (10.5%) were published in the 1990s, and comprised the dependent variable as shown in Table 4,
nine (24%) were published between 2000 and 2009. with the majority (24%) of the 38 studies examining the
Table 33 presents a summary of the demographics of consequences of maltreatment on executive functions
each study, specifically identifying the discipline in which and 2.6% of the studies examining an aspect of executive
the research was generated, the country where the research functions—working memory.
took place, sample size, mean age or age range, gender, The areas of social pragmatic communication that
maltreatment type, and social pragmatic communication were not examined in this literature review were in the areas
component that was identified as the dependent variable. of conversational and expository discourse, as there were no
Studies reviewed were from a range of disciplines (psychi- articles about these topics that met inclusion criteria for this
atry, psychology, speech-language and hearing sciences, study. Table 5 shows the instruments/measures that were
criminology, occupational therapy, medicine, and social used to assess social pragmatic language.
work), with the majority (n = 19, 50%) of studies being com-
pleted by psychologists. Studies were completed in nine dif-
ferent countries. Most of the included studies (n = 19, 50%)
Quality of Articles Included
were completed in the United States, Australia (n = 5, 13.1%), in This Systematic Review
and Spain (n = 4, 10.5%); however, there were also studies A modified version of the PRAT (DeJarnette et al.,
from Brazil (n = 2, 5.3%), Canada (n = 2, 5.3%), China 2012; Hyter et al., 2015) was used to assess the quality of
(n = 1, 2.6%), England (n = 2, 5.3%), Israel (n = 2, 5.3%), the articles that comprised data for this systematic review
and Norway (n = 1, 2.6%). of the literature. Table 6 shows the qualitative judgments
made after reviewing the publications. Fifteen percent of
3
Please note that data in Table 3 (e.g., age range) were entered exactly the data on the article quality was recoded by a graduate
as they were included in the original article; therefore, the age ranges, assistant trained to review the articles and extract informa-
for example, are reported in different formats. tion pertaining to the quality-based criteria. Reliability for

Figure 2. Diagram of studies used in this systemic review.
coding quality of the articles was 94% agreement between communication and their component parts: social cognition,
the author and the graduate assistant. executive functions including working memory, self-regulation,
It is not surprising that all articles provided a clear and pragmatic language.
purpose and goals for their research study, and also either
provided research questions or hypotheses. All articles also
Social Cognition
provided clear findings and discussed the implications of
Social cognition includes theory of mind, perspective
those findings. The majority of articles (n = 29, 76.3%) did
taking, the use of internal state language, and the ability to
not randomize participant pools, and 31 (82%) did not re-
attribute false beliefs to others. Overall, the results of this
port whether or not there was participant attrition. All
study found that children and adolescents with histories of
studies that examined an experimental and control group
maltreatment, as well as those in foster care, have difficulty
mentioned that there were similarities between both groups.
with theory of mind and false belief tasks (Burack et al.,
One study (Shields et al., 1994) did mention that there were
2006; Cicchetti et al., 2003; O’Reilly & Peterson, 2015; Pears
significant differences between groups with regard to ma-
&. Fisher, 2005) compared to matched control groups. The-
ternal education, employment, and number of children. One
ory of mind is generally defined as the ability to think about,
surprising outcome of this systematic review was that only
understand, and respond to one’s own (intrapersonal) and
10 (26.3%) of the 38 studies reported on both the reliability
others (interpersonal) mental, emotional, and cognitive states.
and validity of the measures used to collect data. Of these
False beliefs, perspective taking (the ability to envision or un-
38 articles, 15 (39.5%) did not report reliability and/or valid-
derstand an event from someone else’s vantage point), and
ity of their data collection measures, and 13 (34.2%) re-
the use of internal state language are all social cognitive skills.
ported reliability or validity of the data collection measures,
False belief, an aspect of theory of mind, seems to be depen-
but not both. One reason for this outcome may be that
dent on language abilities (Pyers & Senghas, 2009). False be-
many of the studies used data collection measures that were
lief is the ability to predict what someone might do based on
not standardized, although most measures had been published.
what they believe (Wimmer & Perner, 1983). Two types of
false belief activities are location and content tasks (Gopnik
Major Findings of the Consequences & Astington, 1988; Wimmer & Perner, 1983). An example of
a location task is when a toy figurine (e.g., Renae) puts a ball
of Maltreatment on Social
in a toy box and then goes to get a drink of water. Another
Pragmatic Communication toy figurine (e.g., Michelle) arrives, finds the ball inside of the
The major findings of this study are organized accord- toy box, and when she leaves the area, she puts the ball be-
ing to the Hyter and Sloane (2013) model of social pragmatic hind a tree. The child, who observed these acts “performed”

268

Table 3. Summary of studies’ demographics.
Perspectives of the ASHA Special Interest Groups • Vol. 6 • 262–287 • April 2021
Sample size
Mean age or Social
age range Gender Mean age pragmatic
communication
Study Country Experiment Control Experiment Control Experiment Control Maltreatment type component
1. Alessandri United 15 15 7 F/8 M 7 F/8 M 4–5 4–5 Emotional mistreatment, Social behavior
(1991) States physical and sexual
abuse; neglect
2. Augusti Norway 21 22 14 F/7 M 15 F/7 M 9;48 9;5 Physical abuse, witnessed Executive function
& Melinder violence; witnessed Working memory
(2013) domestic violence;
neglect
3. Beeghley United 20 20 9 F/11 M 8 F/12 M 31 m/22 d 31 m/22 d Physical abuse; physical Internal state lexicon
& Cicchetti States neglect; emotional
(1994) mistreatment
4. Beneden Australia 75 75 38 F/37 M 38 F/37 M 8.35 8.69 Neglect Social skills
et al. (2018)
5. Bernardes Brazil 1554 958 1,065 M Not indiv. 9.72 Not indiv. Reported a maltreatment Executive function
et al. (2020) noted noted score but did not
specify the particular
types of maltreatment
6. Barahal United 17 16 12 M 12 M 7.6 7.6 Physical and sexual Social cognition
et al. (1981) States abuse; maltreatment;
suffered soft tissue
damage
7.Burack et al. Canada 49 49 23 M/3 F 23 M/3 F 10;3 10;27 Physical and sexual abuse Social perspective
(2006) 15 M/8 F 15 M/8 F 15;7 15;5 and neglect; exposure taking
to family violence
8. Cicchetti et al. United 203 143 low 64.5% M 54.5% M 71.99 m 74.17 m Sexual and physical False belief
(2003) States SES abuse; emotional
172 mid maltreatment; neglect;
SES the majority had
experienced two or
more types of
maltreatment
9. Coster et al. United 20 20 9 F/11 M 8 F/12 M 31 m/22 d 31 m/22 d Emotional mistreatment, Communicative
(1989) States physical injury; physical functions
neglect; sexual abuse
10. Demeusy United 45 44 18 M/27 F 24 M/20 F 12;7 m 12;7 m Neglect Working memory
et al. (2018) States
11. Di Sante Canada 45 95 25 M 45 M 42.35 m 42.07 m Neglect or a serious risk Pragmatic skills
et al. (2019) of neglect
12. Fay- Australia 58 49 39% F Not indiv. 4.75 Not indiv. Emotional, physical, Executive function
Stammbach noted noted sexual abuse; neglect
et al. (2017)
13. Greenhoot United 47 24 55% F 55% F 9;0 at YR1 Not indiv. Physical and sexual abuse; Internal state
et al. (2005) States 15;0 at YR6 noted spousal violence language
14. Kay & Green United 63 69 40% M 46% M 176 m 171 m Physical, emotional, Social cognition
(2015) Kingdom sexual abuse; neglect
15. Katz (2013) Israel 7 N/A 1 F/6 M N/A 6–12 N/A Survivors of filicide Narratives
(table continues)

Table 3. (Continued).
Sample size
Mean age or Social
communication
16. Katz et al. Israel 97 N/A 19 M/78 F N/A 9;31 N/A Sexual abuse Emotional language
(2016)
17. Kavanaugh United 17 with 18 60% F with 61% F 15.61 with 15.59 Sexual, physical, Executive function
& Holler States PTSD PTSD PTSD emotional, verbal
(2014) 18 without 61% F 15.19 without abuse; neglect
PTSD without PTSD
PTSD
18. Kim & United 215 206 64% M 64% M 8.11 8.11 Physical and emotional Emotional regulation
Cicchetti States abuse; neglect
(2010)
19. Kirke-Smith United 40 40 14 F/26 M 17 F/23 M 181.92 m 181.1 m Physical, emotional, Executive function
et al. (2014) Kingdom sexual abuse; neglect;
witnessed domestic
violence
20. Lum et al. Australia 82 N/A 40 F N/A 8;2 N/A At least one substantiated Social skills
(2018) 8;2 case of physical,
sexual, emotional
abuse and/or neglect
21. Macfie United 80 27 66 M/41 F Not indiv. 5 5 Sexual and physical Narrative
et al. (1999) States noted abuse; neglect
Hyter: Childhood Maltreatment Social Pragmatic Comm
22. Maughan United 88 51 46.6% M/ 54.9% M/ 5;31 5;31 Physical abuse and/or Emotional regulation
& Cicchetti States 53.4% F 45.1% F neglect
(2002)
23. Mezzacappa United 78 48 78 M 48 M 10.5 10.5 Physical and sexual abuse Executive function
(2001) States
24. Moreno- Spain 74 N/A 41 M/33 F N/A 6–18 N/A Neglect and/or rejection Pragmatic language
Manso et al. by parents; physical or
(2010) psychological
maltreatment; sexual

abuse; serious physical
neglect; separated due
to parental incapacity
25. Moreno- Spain 66 N/A 37 M/29 F N/A 12–17 N/A Physical neglect, physical Social cognition
Manso, and/or psychological
Garcia- abuse and sexual
Baamonde, abuse
Blazquez-
Alonso, et al.
(2016)
(table continues)
269

270

Sample size
Mean age or Social
communication
26. Moreno- Spain 66 N/A 37 M/29 F N/A 12–17 N/A Physical neglect; physical Social competence
Manso, and/or psychological
Garcia- abuse and sexual
Baamonde, abuse
Guerrero-
Barona, et al.
(2016)
27. Moreno- Spain 66 N/A 37 M/29 F N/A 12–17 N/A Physical neglect, physical Social communication
Manso et al. and/or psychological
(2017) abuse; sexual abuse
28. Mothes Brazil 43 40 Not reported Not reported 14;21 14;03 Maltreatment, multitype Executive function
et al. (2015) maltreatment
29. O’Reilly & Australia 52 53 28 M/24 F 22 M/31 F 9;02 8;44 Abuse and/or neglect Theory of mind
Peterson
(2015)
30. Panlilio United 834 N/A 438 M/396 F N/A 3–5 N/A Physical, sexual, Emotion regulation
et al. (2018) States emotional abuse
and neglect
31. Pears & United 60 31 48% M 45% F 4;29 4;4 Physical, sexual, Theory of mind
Fisher (2005) States emotional abuse,
neglect
32. Robinson United 66 57 42.4% F/ 52.6% F/ 9;71 11;85 Physical, sexual abuse; Emotional
et al. (2008) States 57.6% M 47.4% M neglect; emotional regulation
maltreatment
33. Shields United 81 48 29 F/52 M 16 F/32 M 10;08 9;85 Physical and sexual Self-regulation
et al. (1994) States abuse; neglect
34. Snow et al. Australia 83 N/A 40 M/43 F N/A 7;9 N/A Physical, sexual and Narrative
(2019) emotional abuse;
neglect
35. Spann et al. United 30 N/A 15 M/15 F N/A 14;8 N/A Emotional, physical and Cognitive flexibility
(2012) States sexual abuse; neglect (executive function)
36. Toth et al. United 80 27 36% F 44% F 5;04 4;98 Neglect, physical and Narrative
(1997) States sexual abuse
37. Toth et al. United 87 39 29% F 35% F 3;73 T1 3;93 T1 Neglect, physical and Narrative
(2000). States 4;69 T2 4;87 T2 sexual abuse
38. Zou et al. China 107 violent 107 107 M 107 M 16;5 16;5 Emotional, physical, Executive function
(2013) 107 107 M 16;6 sexual abuse, emotional
nonviolent neglect; physical neglect
Note. Gender and age are reported in the same way they were reported in the source article. Sometimes gender is reported as only percentage of females or males; at other times,
it is reported as number of males and females. Ages are presented in years (years;months) unless noted with m (months) and/or d (days). F = female; M = male; SES = socioeconomic
status; N/A = no control group; PTSD = posttraumatic stress disorder; T = time; YR = Year.

Table 4. Number and percentage of studies focusing on specific social pragmatic communication components.
Social pragmatic communication component No. of studies %
Executive functions 9 24.

Emotional/self-regulation 5 13.1
Social skills/social competence 5 13.1
Narrative 5 13.1
Theory of mind (social perspective taking/false belief) 4 10.5
Pragmatic language/communicative functions 3 7.9
Social cognition 3 7.9
Internal state language 3 7.9
Working memory 1 2.6
Total studies 38 100.
by the figurines, is then asked to predict where Renae will than their peers without maltreatment histories, as determined
believe her ball is located. A content task is similar to the lo- by the social information processing model. Moreno-Manso,
cation task but focuses on the content of a box, for example, Garcia-Baamonde, Guerrero-Barona, et al. (2016), like Kay
rather than the location of an object. During this content and Green (2015), found that adolescents with histories of
task, a child is shown a crayon box, but rather than contain- maltreatment tended to be suspicious of and mistrust others.
ing crayons, the box contains cotton balls. The child is then They scored below average on all prosocial attitudes mea-
asked to predict what someone else (who had not seen the sured by the Actitudes y Estrategias Cognitivas Sociales
contents of the box) would say is in the box. Children with (AECS; Social Cognitive Attitudes and Strategies; Moraleda
histories of maltreatment have difficulty with both location et al., 2004), an instrument to measure social, cognitive, atti-
and content of theory of mind tasks. tudes, and strategies. The adolescents with maltreatment his-
Theory of mind does increase with age in this popu- tories were rated high on impulsiveness, independence, and
lation, but at a slower rate than in peers without maltreat- inflexible thinking and had high scores on difficulty identify-
ment histories (O’Reilly & Peterson, 2015). The O’Reilly ing information to solve a problem and solutions to prob-
and Peterson (2015) study utilized the “well-validated ToM lems and difficulty anticipating consequences.
Scale” developed by Wellman and Liu (2004, p. 97). One Toddlers with maltreatment histories used less de-
fascinating outcome of the O’Reilly and Peterson study was scriptive speech about their own activities and feelings and
that a later developing theory of mind task, called hidden made comments less relevant to the ongoing conversation
emotions, was not difficult at all for children with histories than their peers without maltreatment experiences (Coster
of maltreatment—even for children who exhibited delays et al., 1989) and also produced significantly fewer internal
with the simpler theory of mind task, first-order belief. state words and internal state word types than their peers
Children and adolescents with maltreatment histories without histories of maltreatment (Beeghley & Cicchetti,
are more egocentric and have lower levels of self-worth. 1994). Beeghley and Cicchetti (1994) found that toddlers
Children with fewer internalizing (e.g., withdrawn, anxious) with maltreatment histories did not often attribute internal
and externalizing (e.g., aggressive) symptoms are better at states to themselves and to others; however, those with more
negotiating new relationships (Burack et al., 2006). Barahal secure attachment may have had less impaired internal state
et al. (1981) found that children with histories of maltreat- language. Secure attachment refers to the early social con-
ment more frequently attributed the locus of control to others; nections that create a secure, calm, and safe existence for a
that is, outcomes of events (e.g., receiving a compliment or child. The internal state language used by teens with an abuse
losing money; p. 511) were controlled by others or by exter- history varied based on this childhood history of maltreat-
nal factors rather than by themselves, particularly if out- ment. In other words, teens with histories of maltreatment
comes were negative (Barahal et al., 1981). Children with used fewer internal state words related to emotions than their
histories of maltreatment were less likely to take responsibil- peers, but only for memories related to negative events
ity for negative outcomes than their peers. Children with (Greenhoot et al., 2005), which may make it difficult for
histories of maltreatment were also less able to identify and teens with histories of maltreatment to express and evaluate
predict others’ perspectives, as well as emotional states their childhood memories. Other internal state words related
(e.g., feelings) of others, and describe causes associated with to psychological, cognitive, and perceptual states did not
those feelings (Barahal et al., 1981). vary based on abuse history.
Kay and Green (2015) found that a high-risk group The forensic interviews of children who were 3–
of adolescents living in out-of-home placements had poorer 14 years old and had been sexually abused were examined
abilities than their peers on an advanced theory of mind for internal state words. Katz et al. (2016) found that there
task (strange stories task), but the differences between these was a limited presence of emotional internal state words
two groups did not hold when language ability was consid- that occurred in these interviews, and when the emotional
ered. Also, this group of children with maltreatment history words did occur, they were primarily negative emotional
was more likely to attribute hostility to others’ behavior states. The negative emotional state words, however, were

Table 5. Social communication and language assessment tools.
Number Study Tools used to measure social pragmatic communication
1. Alessandri (1991) • Videotaped observations of social participation and level of cognitive play
• Used scale consisting of 11 mutually exclusive and exhaustive categories
• Solitary playing alone; parallel play; group play; functional; constructive; dramatic; games
with rules; imitative; fantastic; self-transformations
• Nonplay categories (unoccupied, transitional, onlooker, teacher conversation, peer
conversation aggression)
2. Augusti & Melinder (2013) • Cambridge neuropsychological test automated battery—spatial working memory test
measures
• Delis–Kaplan Executive Function System color–word interference test
3. Beeghley & Cicchetti (1994) • Maternal interview about child’s internal state words
• Lab observations of child’s spontaneous use of IS words in different contexts
• Semistructure play with stranger
• Emotions picture book task
• Unstructured mother–child free-play
4. Beneden et al. (2018) • Test of Narrative Language
• Social Skills Improvement System Rating Scales
5. Bernardes et al. (2020) • Inhibitory control measures—modified form of Stroop (M-Stroop_ability to control
impulse to press button)
• Go/no-go— assesses inhibitory control
• The Rey–Osterrieth Complex Figure Test was used to evaluate visuospatial or planning,
problem solving, and motor functions
• Cognitive flexibility = 5-point test.
6. Barahal et al. (1981) • Locus of control—Stanford Preschool Internal External Scale (assess child’s beliefs
in their impact on events)
• Social sensitivity (Rothenberg, 1970)
• Cognitive perspective taking—boy–dog–tree test
• Understanding social roles puppet procedures by Watson
7. Burack et al. (2006) • Chandler’s bystander cartoons test to measure the extent to which child and adolescents
set aside privilege or personal knowledge and emotional and take perspective of another
person
• Interpersonal negotiation strategies interview
• Self-perception profile
8. Cicchetti et al. (2003) • False belief tasks—2 unexpected content tasks “smarties” and “book task”
9. Coster et al. (1989) • Assessment of communicative behavior—analysis of social/pragmatic function of child’s
utterances
• Conversational relatedness—conversational relevance
10. Demeusy et al. (2018) • Three boxes stationary—valid measure of spatial working memory
• Three boxes scrambled—valid measure of nonspatial working memory
11. Di Sante et al. (2019) • Language Use Inventory: French
12. Fay-Stammbach et al. (2017) • Coping with children’s negative emotions scale
• Happy-Sad Stroop; tapping test; dimensional change card sort
13. Greenhoot et al. (2005) • Childhood autobiographical memory interview coded for internal state language
14. Kay & Green (2015) • ToM = strange stories task by Happé (1994)
15. Katz (2013) • Narrative analyses—thematic analysis
16. Katz et al. (2016) • NICHD investigative interview protocol were coded using a system based on a previous
hierarchical scale developed by Laurent and colleagues—PANAS-C scale, which
assesses 30 feelings and categorizes them as reflecting positive or negative emotions.
17. Kavanaugh & Holler (2014) • Executive functioning—five subdomains: planning/problem solving, set shifting/
cognitive flexibility, response inhibition/interference control, fluency, and working
memory/simple attention
• Planning/problem solving = Wisconsin Card Sorting Test
• Set shifting = Trial-Making Test
• Response inhibition = Stroop Test
• Fluency = Controlled Oral Word Association Test
• Working memory = Wide Range Assessment of Memory and Learning
18. Kim & Cicchetti (2010) • Emotion regulation checklist
• Peer nominations
• Teacher’s report form—children’s internalizing and externalizing symptomatology
19. Kirke-Smith et al. (2014) • Executive Loaded Working Memory (ELWM)
• Nonverbal ELWM assessed using the odd-on-out task
• Fluency = Verbal Fluency Test
• Nonverbal fluency measured with the Design Fluency Test
• Nonverbal switching = Design Fluency Test (D-KEFS)
• Inhibition—verbal inhibition/motor inhibition task
• Inhibition = D-KEFS Color Word Interference Text
20. Lum et al. (2018) • Social Skills Improvement System Rating Scales
(table continues)

Number Study Tools used to measure social pragmatic communication

21. Macfie et al. (1999) • McArthur Narrative Coding Manuals
• McArthur Story Stem Battery
22. Maughan & Cicchetti (2002) • Anger simulation—designed to observe children’s emotional behavioral responses and
regulation strategies in response to interadult anger
• Post anger simulation—describe how they felt when the research assistant was angry
with their mother and what they would they have done during the angry exchange
• Coding EMRPs—emotion regulation patterns
23. Mezzacappa (2001) • Executive functions—the stop signal task; the Passive Avoidance Learning Task,
experimenter observations during testing—redirections
24. Moreno-Manso et al. (2010) • Objective Language Criteria Test (BLOC-Screening)
• Pragmatic module made of 13 evaluation blocks: greetings, and farewells; attracting
attention; requesting, giving or refusing permission; asking for specific information;
asking for confirmation or refusal, who/what where/when/whose, why how showing
approval/disapproval, direct demands or action, indirect demands for action, protests
25. Moreno-Manso, Garcia-Baamonde, • BLOC-S test—used to evaluate social competence = objective language criteria test
Blazquez-Alonso, et al. (2016) (block screening)
• AECS instrument—social competence—use of language in communicative and social
interaction situations
• AECS = social cognitive strategies and attitudes, Moraleda et al., 2004)
26. Moreno-Manso, Garcia-Baamonde, • AECS to measure social competence
Guerrero-Barona, et al. (2016)
27. Moreno-Manso et al. (2017) • Objective Language Criteria Battery (BLOC-Screening) to measure social communication
• Pragmatic competence through use of language in communicative and social interaction
situations with respect to different functions or uses
• Using drawings in different characters appear in various communicative contexts—told
what the characters’ intention is
28. Mothes et al. (2015) • Arithmetic and digit span subtests of the Wechsler Intelligence Scale for Children
• FAS oral word association test—assesses verbal fluency
• Trail-making test—assesses attention, cognitive flexibility, visual processing speed
• Hayling test—initiation, inhibition, verbal planning and cognitive flexibility
29. O’Reilly & Peterson (2015) • False belief tasks—change location test
• Content task
• Belief emotion test
• Second-order false belief task (Perner & Wimmer, 1985)—window procedure
• ToM Scale Tasks (Wellman & Liu, 2004)
• Spontaneous use of cognitive verbs
30. Panlilio et al. (2018) • Emotion regulation = child behavior checklist from anxious depressed attention and
aggression subscales
31. Pears & Fisher (2005) • Emotion understanding tasks (Denham, 1986)
• Theory of mind tasks—perception tasks
• Desire tasks
• Belief tasks
• Appearance reality task
• Executive Function = Stroop Test & Card Sort
32. Robinson et al. (2008) • Emotion regulation
• Parent–child interatom procedure
• Affect intensity measured using the mean of all individual segment scores from the
parent–child interaction procedure—free-play, bubbles, cleanup, and teaching tasks
• Effortful control was measured by level of persistence and frequency of on task
behavior during the parent–child interaction
33. Shields et al. (1994) • Social competence = used California Child Q-Set
• Counselor behavior ratings (aggressive, prosocial, withdrawn)
• Observations interactions with peers (behavioral dysregulation [coded as act out]
and social interaction [coded as ob-social])
• Emotion regulation—valence and functional/significance of emotion expressions
34. Snow et al. (2019) • Narrative language skills assessed using Test of Narrative Language
35. Spann et al. (2012) • Wisconsin Card Sorting Test
36. Toth et al. (1997) • The MacArthur Story Stem Battery
37. Toth et al. (2000) • Attachment Story-Stem Completion Task (similar to MacArthur but different stems)
38. Zou et al. (2013) • IED—assess flexibility or set shifting
• SOC—derived from the Tower of Hanoi task, which assess planning ability
• SWM tasks = ability to retain spatial information and to manipulate remembered items
in working memory
Note. IS = Internal State; ToM = theory of mind; NICHD = National Institute of Child Health & Human Development; PANAS-C = Positive and
Negative Affect Schedule for Children; IED = Intra/Extradimensional Shift Test; SOC = Stockings of Cambridge Test; SWM = Spatial Working
Memory Test.

Table 6. Qualitative characteristics of articles reviewed.
274

No. of Age of Gender of
participants participants participants Ethnicity/ Similarities Reliability

Purpose/ race SES Attrition Trauma between of Validity of
Study hypotheses Experi. Control Experiment Control Experiment Control noted noted noted noted Randomization groups measures measures
Alessandri + + + + + + + + + No + No + + +
(1991)
Augusti & + + + + + + + + No + + No + +/− No
Melinder
(2013)
Beeghley & + + + + + + + + + No + No + No +
Cicchetti
(1994)
Beneden + + + + + + + No No No + No + +/− +/−
et al.
(2018)
Bernardes + + + + + + + No + No No No + No No
et al.
(2020)
Barahal et al. + + + + + + + + + No + No + No No
(1981)
Burack et al. + + + + + + + + + No + No + + +
(2006)
Cicchetti + + + + + + + + + No + No + + +
et al.
(2003)
Coster et al. + + + + + + + + + No + No + No No
(1989)
Demeusy + + + + + + + + + + + + + + +
et al.
(2018)
Di Sante + + + + + + + No + No + No + + +
et al.
(2019)
Fay- + + + + + + + + + No + No + + +
Stammbach
et al.
(2017)
Greenhoot + + + + + + + + + + + No + + No
et al.
(2005)
Kay & Green + + + + + + + + + No + No + No No
(2015)
Katz (2013) + + n/a + n/a + n/a No No No + No n/a No No
Katz et al. + + n/a + n/a + n/a No No No + + n/a No No
(2016)
Kavanaugh + + + + + + + No No No + No + No No
& Holler
(2014)
Kim & + + + + + + + + + No + No + + +
Cicchetti
(2010)
(table continues)


Kirke-Smith + + + + + + + No No No + No + + +/−
et al.
(2014)
Lum et al. + + n/a + n/a + n/a No + No + No n/a + No
(2018)
Macfie et al. + + + + + + + + + No + + + No No
(1999)
Maughan & + + + + + + + + + No + No + No No
Cicchetti
(2002)
Mezzacappa + + + + + + + + + + + + + +/− +/−
(2001)
Moreno- + + n/a + n/a + n/a + + No + + n/a No No
Manso
et al.
(2010)
Moreno- + + n/a + n/a + n/a + + No + + n/a No No
Manso,
Garcia-
Baamonde,
Blazquez-
Alonso,
et al.
(2016)
Hyter: Childhood Maltreatment Social Pragmatic Comm
Moreno- + + n/a + n/a + n/a No No No + No n/a + No

Manso,
Garcia-
Baamonde,
Guerrero-
Barona,
et al.
(2016)

Moreno- + + n/a + n/a + n/a No No No + + n/a + No
Manso
et al.
(2017)
Mothes + + + + + No No No No No + + + No No
et al.
(2015)
O’Reilly & + + + + + + + No +/− +/− + No + No No
Peterson
(2015)
Panlilio + + n/a + n/a + n/a + No No + No n/a + +
et al.
(2018)
(table continues)
275

276


Pears & + + + + + + + + + No + No + + No
Fisher
(2005)
Robinson + + + + + + + + + No + No + + No
et al.
(2008)
Shields + + + + + + + + + No + No + + +
et al.
(1994)
Snow + + n/a + n/a + n/a + + No + No n/a + +
et al.
(2019)
Spann + + n/a + n/a + n/a + + No + No n/a + No
et al.
(2012)
Toth + + + + + + + + + No + No + No +
et al.
1997
Toth + + + + + + + + + + + + + No No
et al.
(2000)
Zou + + + + + + + No No No + No + No No
et al.
(2013)
Note. SES = socioeconomic status; n/a = not applicable.

used less frequently in the forensic interviews of younger maltreatment types in their history performed less well than
(3–4 years old) children, which might simply be a result of their peers with a single maltreatment type and the control
the younger children’s limited repertoire of emotional words. group on verbal processing and initiation. Using the Passive
One implication is the importance of examining how emo- Avoidance Learning Task (Gray, 1987), which assesses one’s
tional states can be supported in narrative instruction. For ability to avoid producing behaviors that would receive a
example, questions about emotions can be asked, such as negative response, such as punishment, Mezzacappa (2001)
“you said you were sad, tell me more about that” (p. 256). found that adolescents with abuse histories were also found
to be less able to avoid making responses to a task that re-
Executive Functions: Mental Flexibility, Inhibition, sulted in adverse consequences. Zou et al. (2013) examined
and Working Memory the executive function skills of juvenile offenders with his-
Most of the studies reviewed in this systematic review tories of maltreatment who were violent offenders (persons
revealed that children with histories of maltreatment often who commit violent acts) compared to those who were
have difficulty with the executive functions. The three types not violent offenders and found that the violent offenders
of executive functions that are most frequently measured in showed impaired executive functions of mental flexibility,
the literature are mental flexibility, inhibition, and working working memory, and planning.
memory (Augusti & Melinder, 2013; Demeusy et al., 2018;
Diamond, 2013; Fay-Stammbach et al., 2017; Kavanaugh Self-Regulation/Emotional Regulation
& Holler, 2014; Kirke-Smith et al., 2014; Mezzacappa, The studies reviewed for this article show that maltreat-
2001; Mothes et al., 2015; Zou et al., 2013). Mental flexibil- ment history can be predictive of emotional and self-
ity, often referred to as shifting or set shifting, is the ability dysregulation (Kim & Cicchetti, 2010; Maughan & Cicchetti,
to alter one’s focus from one event to another or to modify 2002; Panlilio et al., 2018; Robinson et al., 2008; Shields
one’s perceptions (Diamond, 2013; McCloskey et al., 2009). et al., 1994), limited abilities to self-regulate influences so-
Inhibition is the ability to prevent (inhibit) a response or cial competence (Shields et al., 1994), and peer relationships
thought (Diamond, 2013). Working memory is the ability (Kim & Cicchetti, 2010), and placement instability (moving
to hold on to some information while also processing other homes frequently) may contribute to emotional dysregula-
information (Dehn, 2008; Diamond, 2013). One study tion (Panlilio et al., 2018). Children with histories of mal-
(Bernardes et al., 2020) did not show an association be- treatment may have emotional regulation patterns that are
tween maltreatment and executive functions of cognitive/ underresponsive. In other words, children with maltreat-
mental flexibility, inhibition, or working memory. Other ment history may exhibit low regulation abilities in response
studies showed that children with maltreatment histories to positive and negative emotions that make it look like
perform more poorly on spatial working memory than the child is indecisive, disorganized, or not goal oriented
peers without maltreatment histories, but not with regard (Maughan & Cicchetti, 2002, p. 1527). They may also
to mental flexibility and inhibition (Augusti & Melinder, present as overcontrolled, for example, minimal emotional
2013). response to events in which expressions of distress are inhib-
Infants who experienced neglect had poorer outcomes ited. Robinson et al. (2008) found that emotional dysregu-
in spatial working memory and high rates of aggression in lation was associated with internalizing symptoms, that is,
toddlerhood (Demeusy et al., 2018). Fay-Stammbach et al. children with maltreatment histories showed more inter-
(2017) found that executive function performance was nega- nalizing symptoms (e.g., anxiousness) and less positive af-
tively associated with multiple types of abuse. They also fect compared to their peers. On the other hand, Kim and
found that punitive reactions (adverse reactions) to a child’s Cicchetti (2010) found that lower emotional regulation was
negative emotions, for example, may have a negative influ- associated with higher externalizing symptoms (e.g., aggres-
ence on executive functions in children with maltreatment sion) and often contributed to children being rejected by
histories. Kavanaugh and Holler (2014) found that, in ado- their peers. The more the child was able to regulate their
lescents who have been maltreated, there were lower execu- emotions, the higher the peer acceptance. Children with
tive function skills whether or not an adolescent was also high levels of emotional dysregulation also scored lower
diagnosed with posttraumatic stress disorder. The maltreated than their peers on measures of reading and math achieve-
adolescents with posttraumatic stress disorder diagnosis ex- ment (Panlilio et al., 2018).
hibited lower language skills, problem-solving skills, and
increased anxiety and depression symptoms. Similarly, Pragmatic Language—Communicative Functions
Kirke-Smith et al. (2014) found that adolescents had sig- The articles that examined pragmatic language skills
nificantly lower performance than their peers on working found that children who have been maltreated have poorer
memory, fluency, and inhibition; set shifting was not im- pragmatic language skills than their nonmaltreated peers.
paired, however. Toddlers who experienced maltreatment, whose communi-
An interesting finding by Mothes et al. (2015) is that cative behavior was assessed during unstructured free-play
adolescents with a single type of maltreatment performed with a parent, were shown to be less informative when they
less well than their peers with multiple types of maltreatment talked, less descriptive when talking about the activities
and the control group on cognitive flexibility and visual pro- in which they were engaged and when talking about their
cessing speed. On the other hand, adolescents with multiple feelings, provided utterances that were less relevant to the

context, and made fewer requests for information (Coster A thematic analysis of the stories of children between
et al., 1989). The toddlers who were maltreated also made the ages of 6–12 years who survived attempted filicide
less references to people, places, and objects that were out- (Katz, 2013) revealed that children did not automatically
side their immediate interactive context when compared to refer to their attempted murder even when asked in a fo-
their nonmaltreated peers (Coster et al., 1989). rensic interview whether something bad happened to them.
Three-year-old children with histories of neglect per- It was not until the interviewer said, “Tell me about what
formed poorer on all aspects of pragmatics as measured happened that made you go to the hospital” (p. 765), the
by the Language Use Inventory–French (Pesco & O’Neill, children provided more details, although scant, about their
2016), a 177-item parent questionnaire. Children with ne- traumatic experiences. All of the children are reported to
glect performed less well than their nonneglected peers in have had difficulty remembering what happened. The chil-
all areas—words the child uses; requests for help; uses of dren reported multiple abuse incidents, and a majority of
words to get someone’s attention; asking questions or mak- them did not differentiate the attempted filicide from other
ing comments about things, themselves, and/or other peo- types of abuse and did not provide details about what hap-
ple; use of words when engaged in activities with others; pened to them. The narratives of children with this particu-
sense of humor; showing interest in language; being able lar type of abuse history were limited in informativeness,
to adapt one’s conversation to the needs of the interlocutor; possibly because the filicide was not remembered as a unique
and how the child uses longer sentences and tells stories incident given that the children experienced maltreatment
(Di Sante et al., 2019). many times before the attempted filicide. Also, undoubtedly,
Six- to 18-year-old children who were living in resi- the children experienced high levels of stress during the at-
dential child care resulting from maltreatment all performed tempt on their lives, and these high levels of stress could limit
poorly on a pragmatic language measure designed to exam- “encoding and storage” of information (p. 767). Children
ine the child’s ability to respond to questions from the per- with neglect histories also had more negative representations
spective of another person (character). This difficulty was of themselves in narratives than their peers (Toth et al., 1997,
similar across age ranges (Moreno-Manso et al., 2010). Spe- 2000), but interestingly, children with sexual abuse histories
cifically, this group of children in residential care exhibited have more positive self-representations than children with
difficulty requesting information, formulating and respond- neglect histories (Toth et al., 1997). Additionally, children
ing to questions, and maintaining attention. with histories of maltreatment included fewer representa-
tions of a disciplining parent and more “grandiose self-
Pragmatic Language—Narrative representations” through the production of inflated or
Narrative differences were found between children extraordinary abilities (e.g., being able to lift a car or to
with histories of maltreatment and those without or with fight off a gang) than did children without maltreatment
a history of neglect only (Katz, 2013; Macfie et al., 1999; histories (Toth et al., 2000, p. 282).
Snow et al., 2019). Researchers also found that there was a Children with maltreatment histories between the ages
correlation between the core language scores of the Clinical of 5 and 12 years who were placed in out-of-home care
Evaluation of Language Fundamentals–Fourth Edition (i.e., meaning that they lived outside their immediate parents’
(Semel et al., 2003) and the comprehensive score on the homes but could live in foster care, with other relatives [e.g.,
Test of Narrative Language (TNL; Gillam & Pearson, Aunt], or in residential centers) performed below average on
2004), that there was no relationship between household a formal narrative analysis tool (TNL; Gillam & Pearson,
income or SES and narrative outcomes on the TNL, and 2004). Specifically, 42% of the 83 children assessed in this
that female caregivers’ education level is positively associated study received a below average Narrative Language Ability
with overall narrative language skills (Snow et al., 2019). Index (a comprehensive narrative score) yet scored at or
In a study in which the goal was to determine how above average on narrative comprehension.
parents and children were depicted in the narratives of pre- A significant implication of these results is that children
schoolers who had experiences of physical abuse, sexual with histories of maltreatment are often required to provide
abuse, or neglect only, preschoolers were provided with an account (narrative) about their maltreatment during a
story stems about stressful family situations from the forensic interview or even during a trial of the perpetrator
MacArthur Story Stem Battery (Macfie et al., 1999). Children (Powell & Snow, 2007). Children may not be able to tell
with histories of physical and sexual abuse engaged in role compelling stories about their experiences or adequately
reversal more often than children with only histories of participate in psychosocial interventions that require this
neglect; that is, they portrayed themselves as a caretaker skill.
(e.g., parent), rather than a child, in their stories. This
group of children took on the role of being responsible Social Skills/Social Competence
for alleviating the distress being experienced by the child Children with histories of maltreatment engage in
character in the story. Additionally, preschoolers with physi- less functional play than their peers and in more aggressive
cal and sexual abuse histories more frequently portrayed behaviors. They also have increased negative interactions
parents and children as less responsive to the other charac- with their teachers and engage in less group play and in
ters in their stories than did children with only a history of more concrete play (Alessandri, 1991). There is prelimi-
neglect. nary evidence that children with histories of maltreatment

(particularly with a history of neglect) respond more to sug- states but exhibited limited internal state words particularly
gestibility than do their peers without maltreatment histo- when recounting their own childhood memories.
ries. Suggestibility is when questions are asked in a way that Implications of these findings are that assessments
directs the child toward a particular response, for example, should include and interventions should focus on helping
“Is it true he had a gun?” (Beneden et al., 2018, p. 52). Sug- children with histories of maltreatment develop and utilize
gestibility, however, was positively correlated with commu- perspective taking, theory of mind, false belief, and inter-
nication abilities suggesting that it might be a protective nal state language. These social cognitive skills will support
factor; that is, children learn to anticipate adults-preferred the child’s ability to develop and maintain positive peer in-
responses and comply with adults as a way of keeping teractions (O’Reilly & Peterson, 2015). Intervention could
themselves safe (Beneden et al., 2018). Lum et al. (2018) include direct teaching of emotional states by exploring
found that, on a standardized test of social skills (Social others’ motivations, teaching specific vocabulary that per-
Skills Improvement System Rating Scales; Gresham & tain to these states, as well as teaching these states through
Elliott, 2008), children with maltreatment have low scores modeling and play (Yehuda, 2016).
on social skills. Social skills were correlated with maltreat-
ment history, but language skills were not. Education level
of the child’s caregiver was positively correlated with the Executive Functions
child’s language skills. Children with histories of maltreatment generally have
more problems with spatial working memory and with
inhibiting responses than their peers without maltreatment
Discussion and Implications histories, although the ability to engage in mental flexibil-
ity seems intact. This population of children was found to
This systematic review of 38 research articles exam- have more difficulty avoiding behaviors that would result
ined the consequences of maltreatment on social pragmatic in some type of negative response, such as receiving a pun-
communication in children and adolescents. The results of ishment or time-out. Working memory is important for
this study show that the majority of articles that met inclu- language comprehension, incorporating new information
sion criteria focused on social cognitive skills and execu- into one’s thinking, and making connections among various
tive functions. Findings that stood out from this review are ideas (Diamond, 2013). The literature on working memory
their implications for speech-language hearing science pro- (an aspect of executive functions) primarily focused on spa-
fessionals, which are presented in Table 7. tial working memory. This is not unusual, as much of the
literature on working memory regardless of the population
examined focuses on symbol systems related to visuospatial
Social Cognition skills. Working memory and other executive functions are
The reviewed literature showed that children with essential for social communication and interpersonal rela-
maltreatment histories had difficulty with theory of mind tionships (Coggins et al., 2003; Crick & Dodge, 1994; Hyter,
tasks, including perspective taking, use of internal state 2012; Mackelprang et al., 2009; Waite, 2013). What is
language, and attributing false beliefs to others. The ability needed, particularly for speech-language hearing scientist
to use theory of mind increased with age in this population professionals, are more ecologically based tools that mea-
but at a slower rate than their peers without a history of sure a child’s ability to employ executive functions in
maltreatment. In a task that evaluated children’s’ ability to everyday social interactions with peers and others in real
understand that people might hide negative emotions, such time (Gerlach et al., 2011; Waite, 2013).
as anger, children with histories of maltreatment did not Implications of these findings are that more real-time
have an impaired ability to identify hidden emotions, al- performance-based assessments are needed to determine
though this ability requires higher levels of theory of mind. children’s ability to utilize executive functions, including
This finding might be due to children’s history with being working memory, in day-to-day peer interactions. Interven-
on the receiving end of negative emotions. This past ex- tions that incorporate mindfulness are increasingly being
perience might have helped them become more aware that used to support executive function skills of individuals with
others may conceal emotions (O’Reilly & Peterson, 2015; trauma histories, which is a practice that has been shown
Wellman & Liu, 2004). Children with histories of maltreat- to facilitate resilience—the ability to adapt to change and
ment can identify angry faces but have difficulty predicting adversity (DePrince et al., 2007; Heramis, 2020).
what emotion might be based on a false belief. For exam-
ple, shown a picture of an angry face, a child with a his-
tory of maltreatment can recognize that face as angry but Self- and Emotional Regulation
may have more difficulty determining how a person would Children with histories of maltreatment were found
feel if that person left her chocolate in one cupboard, and to exhibit emotional and self-dysregulation. The literature
when she returned to that cupboard, it had been moved. found that this dysregulation can manifest as both internal-
Young children had more difficulty attributing internal men- izing and externalizing behaviors, which can negatively
tal states and emotions to others, although older children influence their ability to learn and their opportunities for
(teens) were able to attribute internal mental and emotional learning (Panlilio et al., 2018). The implication of this finding

Table 7. Summary of findings.
Pragmatic social
communication Summary of key findings
Social cognition • Children with histories of maltreatment

• generally had difficulty with theory of mind, perspective taking, use of internal state language, and attributing
false beliefs to others;
• appeared to have no difficulty understanding that others could hide negative emotions;
• had significant impairment in the ability to predict thoughts, feelings of others, likely due to the limited models
in their homes of “explanatory discourse about inner mental states” (Cicchetti et al., 2003; O’Reilly & Peterson,
2015, p. 100; Ramírez et al., 2011);
• are able to identify angry faces but not consistently able to predict which emotion would be based on a false
belief.
• Although theory of mind was found to increases with age in children with histories of maltreatment, it increased
at a slower rate than peers without maltreatment histories.
• Young children had difficult to attributing internal mental and emotional states to others; older children (teens)
showed limited using of internal state words related to their own childhood memories.
Executive functions • Children with histories of maltreatment
• have problems with spatial working memory, have the ability to keep spatial information in mind, and is
helpful in navigating spaces, and inhibition;
• seem to be able to engage mental flexibility (e.g., shifting attention from one thing to another) similarly to
peers without maltreatment histories;
• were less able to avoid engaging in behaviors that would receive a negative response.
• There are inconsistent reports regarding whether adolescents with multiple incidences of maltreatment
performed differently than their peers without maltreatment histories.
Self- and emotional • Maltreatment history was shown to be predictive of emotional and self-dysregulation, both of which can
regulation negatively affect social competence and peer relationships.
• Emotional dysregulation can be associated with internalizing behaviors, such as anxiety or with externalizing
behaviors such as aggression or vandalism.
Pragmatic language— • Children with histories of maltreatment and particularly with histories of neglect performed less well on pragmatic
communicative language skills including communicative functions and narration than their peers without trauma histories. They
functions and were found to exhibit:
narrative • difficulty getting attention, asking questions, making comments using words;
• adapting their language to the needs of their conversational partner;
• less references made to people, places, and objects;
• less relevant comments related to the context;
• difficult responding to questions about character perspectives;
• limited informativeness in narratives and when describing activities in which they were engaged.
• Specifically, with regard to narratives, children with histories of maltreatment
• represented themselves as the parent or the person responsible for helping others;
• portrayed the adults (parents) in their narratives as less responsible to other character needs;
• represented themselves negatively or in grandiose fashion (e.g., with superhuman abilities);
• often omitted traumatic events from their stories;
• had below average narrative language index ability on the Test of Narrative Language (Gillam & Pearson,
2004), primarily with regard to narrative production rather than comprehension.
Social skills • Children with histories of maltreatment were shown to have the following in comparison to their peers without
histories of maltreatment:
• less functional and more concrete play;
• more aggressive behaviors or lower levels of prosocial behaviors particularly for children with histories of
neglect—such prosocial behaviors include lack of positive behavior, internalizing behavior problems (anxiety,
withdrawn);
• more susceptible to suggestibility, such as when a desired response is suggested in the way a question is
asked, for example, “You like chocolate, do not you?”
for speech-language and hearing science professionals is that with others as demonstrated by their difficulty gaining
expanding a child’s ability to use emotion words has been others’ attention, asking questions, and using words to com-
shown to positively influence emotional and self-regulation municate their needs. They also made less relevant (contextu-
(Wyman et al., 2010). ally contingent) comments. During narrative assessments,
children with histories of maltreatment exhibited limited in-
formativeness (minimal details) in narrative production and
Pragmatic Language had difficulty with narrative production as measured by the
The articles that focused on pragmatic language pri- TNL (Gillam & Pearson, 2004). Interestingly, children with
marily examined communicative functions and narrative histories of maltreatment portrayed themselves as responsible
production and comprehension. Children with histories of adults in their stories and portrayed parents as nonresponsive
maltreatment exhibited difficulty engaging in interactions or less responsive than other story characters.

Implications of these findings suggest that assess- appropriate assessments and effective interventions to
ments should include narrative production (retelling and children with challenges in the area of social pragmatic
generation), as well as conversational skills. Trauma can communication. A trauma-informed focus is when the
“shut down” language abilities, making it difficult for chil- speech-language and hearing professional realizes the impact
dren who have experienced trauma process and then re- of trauma on the life, social pragmatic communication, and
count events (Yehuda, 2016, p. 191). Yehuda (2016) states language of a child; is able to recognize the symptoms of
that children with histories of maltreatment may have diffi- maltreatment; integrates knowledge about trauma into
culty making connections between events and may need speech-language and hearing practice; and actively resists
“assistance with identifying and understanding causation, retraumatization (Hyter & Ciolino, 2018; Yehuda, 2016).
responsibility, culpability and consequence” (p. 195). These In academic curricula, there may often be emphasis on
are all worthy goals for pragmatic language intervention social pragmatic communication with a focus on autism
with working with a child with a trauma history. Modeling without an equal focus on the neurodevelopmental concerns
narratives will help the child develop these abilities. For related to maltreatment.
example, every day activities can be turned into a story Future research on the impact of maltreatment on
(Yehuda, 2016). Yehuda provides several suggestions for social pragmatic communication should include examina-
ways to use repetition and scaffolding for helping the child tion of social pragmatic communication in real-time contexts,
organize ideas, identify causes of events, sequence events, using ecologically valid social scenarios (Waite, 2013), and/or
and determine relationships and perspectives of story char- during real-time interactions with others (Hyter, 2007, 2017).
acters. Some of the activities she suggests are as follows: To adequately examine social pragmatic communication in
these real-time contexts, future studies should identify
• telling stories about activities relevant to the child
and determine the reliability and validity of multi-informant
and talking about events before, during, and after
multimodal assessment processes for social pragmatic
they take place;
communication
• making “story books” for simple things such as mak- The results of this systematic review confirm that
ing breakfast or going to bed; children and youth with histories of maltreatment have com-
• including drawings or photos of the child’s actions; promised social pragmatic communication skills in com-
and parison to their peers without maltreatment histories. These
difficulties occur across all social pragmatic communication
• retelling the stories to reinforce familiarity (p. 202).
dimensions and their subdimensions as identified in the
Hyter and Sloane (2013) model of social pragmatic com-
Social Skills munication and include social cognition, executive func-
tions, affect/behavior/self-regulation, pragmatic language,
Children with histories of maltreatment were found
and working memory. Challenges to social pragmatic com-
to have less functional play abilities and more concrete play.
munication occur in young children and through adolescence
They also showed higher levels of aggression, lower proso-
and influence peer relationships and academic outcomes,
cial behaviors, and difficulty establishing interpersonal re-
suggesting that early intervention is imperative for all chil-
lationships. These children were also more susceptible to
dren with maltreatment histories. To reiterate an appeal
suggestibility. Asking questions in a way that suggests there
from Sylvestre et al. (2016), “these results strongly support
is a correct or expected response is likely to get the expected
the deployment of efforts to…counter maltreatment of
response but not necessarily a true response.
children” (p. 55) in all shapes and forms.
Given these findings, clinicians should be careful about
Speech-language and hearing professionals should
how questions are posed to children with histories of mal-
learn to engage in trauma-informed practices. Trauma-
treatment. Additionally, intervention should include a focus
informed practice is where there is a commitment to (a) real-
on language skills that accompany prosocial behaviors.
ize the widespread impact of trauma and understand poten-
tial path for recovery; (b) recognize the signs and symptoms
of trauma in others; (c) respond by integrating knowledge
Conclusions about trauma into policies, procedures, and practices; and
Results of the systematic review of studies have im- (d) to actively resist retraumatization (Substance Abuse
plication for how children are supported in recounting past and Mental Health Services Administration, 2014, pp. 9–
experiences, particularly during court cases and forensic 10). Hyter (2016) and Hyter and Ciolino (2017, 2018)
interviews. These results also have implications for what recommend that speech-language and hearing sciences
areas of social pragmatic communication are assessed and professionals engage in trauma-informed practice that
targeted for intervention and for curriculum knowledge includes the following:
and skills acquired and required by preservice and certified
• engaging in culturally responsive and transdisciplin-
speech-language and hearing science professionals. There is
ary practice;
a strong possibility that these professionals will have children
on caseloads whose maltreatment history is unknown. There- • understanding the impact of trauma on brain and
fore, a trauma-informed focus is essential for providing therefore on the sensory system, emotional regulation,

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Appendix ( p. 1 of 2)
Modified Version of the Primary Research Appraisal Tool

Appendix ( p. 2 of 2)
Modified Version of the Primary Research Appraisal Tool


Childhood Maltreatment Consequences On Social Pragmatic Communication. A Systematic Review of The Literature

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PERSPECTIVES SIG 1

Childhood Maltreatment Consequences

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Inclusion Criteria and Study Selection

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Name Description Database holdings

Table 2. Search terms and combinations.

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Figure 2. Diagram of studies used in this systemic review.

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SIG 1 Language Learning and Education

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SIG 1 Language Learning and Education

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SIG 1 Language Learning and Education

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Social pragmatic communication component No. of studies %

Executive functions 9 24.

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Table 5. Social communication and language assessment tools.

Number Study Tools used to measure social pragmatic communication

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Number Study Tools used to measure social pragmatic communication

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SIG 1 Language Learning and Education

participants participants participants Ethnicity/ Similarities Reliability

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No. of Age of Gender of

Moreno- + + n/a + n/a + n/a No No No + No n/a + No

SIG 1 Language Learning and Education

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SIG 1 Language Learning and Education

No. of Age of Gender of

Note. SES = socioeconomic status; n/a = not applicable.

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Hyter: Childhood Maltreatment Social Pragmatic Comm 277

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Table 7. Summary of findings.

Social cognition • Children with histories of maltreatment

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Hyter: Childhood Maltreatment Social Pragmatic Comm 281

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Hyter: Childhood Maltreatment Social Pragmatic Comm 283

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Hyter: Childhood Maltreatment Social Pragmatic Comm 285

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Hyter: Childhood Maltreatment Social Pragmatic Comm 287

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