Clinical Linguistics & Phonetics, June 2012; 26(6): 572575

2012 Informa UK Ltd

ISSN: 0269-9206 print / ISSN 1464-5076 online
DOI: 10.3109/02699206.2012.661830

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BOOK REVIEW
Clinical Pragmatics. Edited by Louise Cummings, 2009 (Cambridge: Cambridge
University Press) [318 pp.]. Price 68.00. ISBN:978-0-521-88845-5.

This thought-provoking book constitutes a valuable and extremely insightful work covering
the wealth of developments, uncertainties and controversies in a rapidly expanding research
field of clinical pragmatics. It exhaustively surveys developmental and acquired pragmatic
disorders and successfully scrutinizes the current state of knowledge giving careful attention
to a variety of approaches and methods in a mostly transparent and readable manner, which
makes it an excellent introduction and a must-read for all interested in clinical pragmatics.
The book is thoroughly researched and illustrated by a highly impressive collection of
studies and show-cases.
The author explicitly defines the contribution she attempts to make with the book. The
primary aim of the book is twofold: first, to survey developmental and acquired pragmatic
disorders; second, to critically evaluate the emerging field of clinical pragmatics, to peruse
its achievements and downfalls and offer a rational appraisal of the current knowledge with
reference to pragmatic disorders, their assessment and treatment in children and adults
(p. 1). Such a critical approach, Cummings claims, is needed for the development of the
field more than accumulating findings from further clinical studies (p. 12).
What can be considered/defined as a pragmatic disorder/impairment has been fervently
debated (compare Hulme & Snowling, 2009; Perkins, 2007; Stainton, 2011) and the discussion seems to primarily stem from differing approaches to defining pragmatics and delineating pragmatic behaviours. Pragmatic disorders occupy a prominent position within clinical
linguistics and, theoretically, important insights should be derived from their outcomes for
better understanding and handling of the pragmatic disorders. The author meticulously
(which makes the text a bit dense and some of its parts repetitive at times) surveys numerous
studies which have been conducted in the field to date and critically reflects on their findings.
The most problematic issue and major critique which Cummings advances is that many of
these studies seemingly lack a solid and rational theoretical grounding. As a consequence,
opulent findings generated by them frequently appear to be unrelated as the investigated
notions are misinterpreted or simply assumed to be pragmatic:
many of the pragmatic impairments that have been identified and examined by clinical
researchers are not pragmatic impairments after all. In some cases, behaviours that are not
pragmatic in any sense of the word have been inaccurately identified as pragmatic in
nature. (p. 229)
Consequently, Cummings claims, such findings cannot form the bases for formulating the
principles of a reliable and effective assessment and intervention. Thus, the undeniable
and most socially painful consequence of such a situation is failure to provide adequate

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and high-quality clinical services for pragmatically disordered individuals. The author supports her argument with numerous examples from a wide range of studies she has examined.
According to Cummings, the confusion results from the lack of developmental milestones in
the acquisition of pragmatics to serve as analytic reference points (pp. 2, 8, 40) (as compared
with well-documented developmental stages concerning phonology or syntax) and a growing
number of both linguistic and non-linguistic behaviours qualified as pragmatic. Thus, the
problem seems to boil down to the abovementioned consideration of how pragmatics, its
scope and pragmatic concepts are/can be/should be defined (pp. 29, 31): what counts as a
pragmatic behaviour and, consequently, as a pragmatic disorder:
this multiplication of pragmatic behaviours has gone too far and behaviours that are
not in any sense pragmatic are now being included in clinical pragmatic studies. (p. 2)
Adding to this confusion is the fact that, on the one hand, clinical pragmatics, constituting
an interdisciplinary area of investigation, does not get sufficiently informed by theoretical developments in fields such as psychology, cognitive and neurocognitive science, psychiatry,
linguistics, speech and language pathology. On the other, meaningful contributions of
these fields to the interdisciplinary knowledge required for positing theoretical explanations
of pragmatic disorders can be limited by the prevailing misconceptions and misunderstandings with regard to the pragmatic concepts investigated (pp. 3, 29, 30):
I attribute this tendency to the erroneous identification of pragmatics with communication, nonverbal communication specifically included. (p. 31)
The author advocates the view that pragmatic competence needs inclusion in the framework of linguistic competence (p. 7) (in the Chomskyan sense of the word). She portrays
clinical pragmatics as a research area preoccupied with outlining the ways in which an individuals use of language to achieve communicative purposes is disrupted (p. 6) and sees
pragmatic competence as an underlying basis for pragmatic behaviour. Importantly, since
pragmatic development with regard to certain skills can extend into adolescence, in some
cases deciphering the nature (developmental vs. acquired) of the pragmatic disorder may
turn out indeed problematic. In addition, not all pragmatic disorders can be directly
traced to brain damage (cerebral pathologies, lesions, injuries or degeneration), as some of
them are clearly divorced from any aetiology of neurological nature (pp. 9, 88).
Extremely informative Chapters 2 and 3 are devoted to detailed description and characterization (with regard to symptoms and diverse possible aetiologies) of the developmental
and acquired disorders, respectively. Notwithstanding the definitional and typological difficulties indicated above, their aim is to present readers with an overview of what clinicians and
researchers define and treat as pragmatic disorders (p. 41) observed in both children and
adults. Cummings stresses that the intensive investigation of developmental pragmatic disorders conducted to date neither has been grounded in any theory of developmental pragmatics, nor has been based on any reliable account of the chronological order in which
pragmatic skills are acquired (p. 40). She pictures developmental pragmatic disorders
which have been researched in relation to four clinical populations, including developmental
language disorder (specific language impairment), autistic spectrum disorders, emotional
and behavioural disorders (attention deficit hyperactivity disorder, conduct disorder, selective mutism) and mental retardation (e.g. Downs syndrome, Williams syndrome).
Chapter 3 deals with pragmatic disorders which occur in individuals who already acquired
most of the pragmatic skills and these skills remained intact until the onset of the disorder.

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Book review

The survey touches upon five clinical populations, including individuals with left-hemisphere
damage, right-hemisphere damage, schizophrenia, traumatic brain injury and neurodegenerative disorders (Alzheimers disease in particular). The study of the acquired pragmatic disorders is promising in that it enables search for neurocognitive substrates of pragmatic
deficits. The search involves examining the neuroanatomical basis of pragmatic processing
in brain-damaged subjects with the use of brain imaging techniques (e.g. functional magnetic
resonance imaging) as well as determining the relation between pragmatics and cognition in
the case of neurodegenerative disorders where certain cognitive impairments attend the
degeneration of specific neural networks. As stressed by Cummings, any attempt to establish
the neural basis for pragmatic behaviour is obviously premature; however, it definitely deserves attention for its potential for enhancing our understanding of pragmatic norm and
impairment.
Cummings considers the potential benefits for advancing the understanding of pragmatic
disorders in children and adults in integrating cognitive and pragmatic theories, which could
result in the development of new theoretical frameworks. In Chapter 4, three cognitive theories of autism, namely the Theory of Mind (ToM), Weak Central Coherence Theory and
Executive Function Theory, are carefully examined against the criterion of pragmatic adequacy (p. 125) and with regard to the relationships that potentially hold between them.
Chapter 5 deals, in turn, with cognitive substrates of acquired pragmatic disorders.
The activities and procedures of assessment and treatment in clinical pragmatics, are
reciprocally related assessment determines treatment and is often integrated into intervention, in which way it can get informed and modified in return. Chapters 6 and 7 examine a
full range of available methods and techniques which clinicians resort to when undertaking
the evaluation and treatment of pragmatic skills in children and adults. The author scrupulously points out to the benefits and pitfalls of a number of assessment methods describing
them in terms of time and effort they require, and, more importantly, the extent to which
their findings can be successfully translated into planning a particular type of treatment.
Due attention is devoted to the following types of instruments: pragmatic profiles and communication checklist (containing descriptive taxonomies of pragmatic behaviours), formal
pragmatic tests (usually supplemented by informal techniques of observation and elicitation),
techniques based on conversational analysis as well as examinations of extended language use
in discourse analysis (including descriptive, procedural and narrative discourse genres).
Cummings anchors her critical evaluation of assessment practices in a thorough revision of
a number of clinical studies and sums it up in a rather sceptical and pessimistic conclusion
that despite the abundance of instruments and tools accessible to clinicians, poor assessment
of pragmatic skills prevails. In addition, a number of these instruments seem to be deficient
in terms of clinical validity and reliability, and some other tools are continually used in clinical settings even though they painfully lack sufficient evidence of their efficacy (p. 180).
As regards intervention, Cummings stresses the apparent lack of consensus and gross
eclecticism in approaches to the treatment of pragmatic disorders (p. 196). Four areas of
remediation within pragmatic language intervention are focused on, namely, training pragmatically disordered individuals in using conversational skills, social communication interventions, pragmatic skills training and treating pragmatic impairments through
remediating cognitive deficits (approaches based on the ToM), for instance, developing
and improving an ability to attribute beliefs and other mental states to the minds of others
and to ones own mind (pp. 119, 207).
Cummings subscribes to the opinion that major faults in research findings she reviews
stem from insufficiently refined scope of pragmatics and core pragmatic concepts, which
in fact brings about considerable uncertainty with reference to which linguistic phenomena

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can be perceived as pragmatic in nature (p. 216). As a consequence, Cummings stresses,

behaviours which should not be interpreted as pragmatic are in fact labelled as such.
The prevailing construal of the term pragmatics simply equates it with the term communication (p. 235).
Cummings blames failed attempts at establishing and detailing the domain of pragmatics
(including pragmatic concepts and behaviours) for challenges and difficulties faced by clinicians working with pragmatically impaired individuals (pp. 216217). She mentions cases
where an individuals pragmatic skills were misinterpreted and pragmatic impairment incorrectly attributed, which in turn led to inappropriate intervention; or, conversely, undamaged
performance was missed in accounts (p. 250). In order to minimize the definitional problems
and help avoid flaws in future research, the author first enumerates the types of errors identified in the examination of clinical studies and then proposes a set of criteria whose role is to
guide researchers towards behaviours she considers pragmatic in nature (pp. 244248).
I may not fully share Cummings rather pessimistic evaluation of several aspects of
research and clinical activity within the field of clinical pragmatics, especially the imperfections and below-standard effectiveness of the assessment and treatment services (cf.
p. 243), which, as she claims, can follow from the findings of clinical studies adopting somewhat haphazardly demarcated boundaries of pragmatic concepts and behaviours. However, I
agree there is room for improvement. I greatly value the authors expertise shown and her
eagle eye for possible inadequacies in study designs, failures in properly defining and understanding the investigated concepts and lack of decent theoretical grounding in clinical investigations as well as her sensitivity to the direct social consequences that any scientific
undertaking in clinical pragmatics entails. A comprehensive overview of the symptomatology,
suggested causes, assessment and treatment procedures the book offers is exceptionally
thorough and based on massive amounts of literature. Altogether, Clinical Pragmatics is a
highly inspiring accomplishment with great potential for raising awareness and triggering
further theoretical explorations and empirical investigations in the field.
References
Hulme, C., & Snowling, M. J. (2009). Developmental disorders of language learning and cognition. Oxford:
Wiley-Blackwell.
Perkins, M. (2007). Pragmatic impairment. Cambridge: Cambridge University Press.
Stainton, R. (2011). Pragmatic impairments. International Review of Pragmatics, 3(1), 8597.

Joanna Nijakowska
Chair of Pragmatics, University of dz
E-mail: jnijak@wp.pl