Impact of Anxiety and Autism Symptomatology on Pragmatic Language in Young Adult Males with Fragile X Syndrome

Background:  Fragile X syndrome (FXS) is the leading inherited genetic cause of autism spectrum disorder (ASD). It is also characterized by high rates of anxiety, with up to 84% meeting criteria for a disorder, resulting in reduced quality of life and increased impairment. It is speculated that anxiety interferes with language learning, particularly during social-interactive contexts resulting in pragmatic language (i.e., social language) impairments. Pragmatic impairments are highly associated with ASD, and investigation into the role of autism and anxiety in FXS on pragmatic language helps address the heterogeneity of behaviors and impairments based on a specific etiology.

Objectives:  This is the first study to examine the effects of autism and anxiety symptoms on pragmatic language in young adult males with FXS using a semistructured, dynamic, conversational assessment. This study will identify specific language vulnerabilities in a syndromic, FXS population with high ASD comorbidity and will provide translational evidence for future treatment to optimize language development in males with FXS with findings relevant for different etiologic groups with ASD.

Methods:  Participants included 25 young adult males (M_age 19.6, SD 2.1) with FXS. The Yale in Vivo Pragmatic Protocol (YiPP; Simmons, 2015) was administered to characterize use of appropriate pragmatic language and the level of contextual scaffolding from the examiner needed to elicit the target skill through error and cue scores. Error scores ranged from 0, appropriate spontaneous, to 2, completely inappropriate responses, and higher error scores are indicative of greater impairment. Cue scores ranged from 0, no response, to 6, spontaneous appropriate answer, and higher cue scores are indicative of better performance and less contextual scaffolding. Autism Diagnostic Observation Schedule-2 (ADOS-2) provided an autism severity index. Two subscales, socially avoidant and generalized anxiety, from the Anxiety, Depression and Mood Scale (ADAMS) assessed dimensional aspects of anxious behaviors to determine if deficits are related to generalized anxious states or isolated to social anxiety. Autism severity, generalized anxiety and socially avoidant behaviors were examined as predictors of language impairment.

Results:  Participants had a mean error score of 1.44 (SD .39) reflecting language responses that tended to be mildly to completely inappropriate and cue scores of 2.41 (SD 1.30) indicating appropriate responses were elicited after greater scaffolding of conversational probes through nonspecific or specific verbal repetition or cues. Higher rates of social avoidance predicted greater language impairments (B=.04, p=.025, R²=.48) and greater need for conversational scaffolding (B=-.11, p=.046, R²=.47) after covarying for expressive vocabulary. Neither autism severity nor generalized anxiety symptoms predicted pragmatic impairments (p’s>.091) or contextual scaffolding (p’s>.159).

Conclusions:  These findings highlight a complex relationship between anxiety and pragmatic language impairments in males with FXS. Results are consistent with a multifaceted interplay of dynamic systems involving language development in that socially avoidant behaviors, but not a pervasive anxious state, negatively impact pragmatic skills. Avoidant behaviors likely reduce environmental opportunities for learning, likely hindering social language development and augmenting avoidance. Continued research on the effects of autism and anxiety on pragmatic language is needed to comprehend similarities and differences across etiologies.