Pronoun Interpretation Problems in Primary School-Aged Children with Autism Spectrum Disorder

Background: Personal pronoun reversal, i.e. saying you when meaning I and vice versa, is a well-known linguistic characteristic of children with Autism Spectrum Disorder (ASD). It is described as an idiosyncratic language problem in the DSM-5 diagnosis of ASD (American Psychiatric Association [APA], 2013). Pronoun reversals are viewed as manifest only in early development (Tager-Flusberg, 1994). However, Mizuno and colleagues (2011) showed that, in interpretation, even adults with high-functioning ASD have problems with personal pronouns and that these problems may be due to a failure in perspective-shifting between the roles of hearer and speaker.

Objectives: This study aimed to determine 1) whether primary school-aged children diagnosed with ASD show problems with pronoun interpretation in situations that require a perspective-shift and 2) which cognitive processes are needed to arrive at a correct interpretation of pronouns in these situations.  

Methods: Forty-eight average functioning children with ASD and 43 typically developing (TD) children (age 6-12) participated in a larger study on language and communication in children with ASD. Clinical diagnosis of children in the ASD group was confirmed by the Autism Diagnostic Interview and/or Autism Diagnostic Observation Schedule. In a pronoun task children watched a short movie with three animals. An example of an item is: Pig whispered something in Frog’s ear. After that Frog reported to Dog: “Pig said: ‘You get the car’”. The participant had to select the correct referent of you. To arrive at the correct interpretation of you, a perspective-shift is needed from the reporting context, where Dog is the referent of you, to the reported context, where Frog is the referent of you. In addition, cognitive tasks were administered to measure these children’s Theory of Mind (ToM), cognitive inhibition, cognitive flexibility, working memory (WM), IQ and verbal ability. 

Results: All children had problems interpreting pronouns in situations that required a perspective-shift. Whereas the TD children made less errors the older they were, the children with ASD did not show improved pronoun interpretation with age. An investigation of the cognitive processes involved in pronoun interpretation in perspective-shifting situations showed that, in all children, ToM, WM, IQ and verbal ability are needed for a better understanding of pronoun interpretation. Specifically for children with ASD, problematic pronoun interpretation was found to be related to second-order ToM understanding. Children with ASD with high second-order ToM understanding did not improve with age in pronoun interpretation, whereas TD children did. 

Conclusions: Our findings suggest that primary school-aged children with ASD show a delayed development of pronoun interpretation. This delay seems to be due to problems with ToM. Our findings suggest that the pronoun interpretation problems in children with ASD should be seen as a perspective-taking problem in language, rather than an idiosyncratic language problem. Also, the pronoun problems in ASD should not be viewed as only manifest in early development, but in later development as well.