Language functioning, mental health and alexithymia

International Journal of Speech-Language Pathology

ISSN: 1754-9507 (Print) 1754-9515 (Online) Journal homepage: http://www.tandfonline.com/loi/iasl20

Language functioning, mental health and alexithymia in incarcerated young offenders Pamela C. Snow, Mary Woodward, Monique Mathis & Martine B. Powell To cite this article: Pamela C. Snow, Mary Woodward, Monique Mathis & Martine B. Powell (2015): Language functioning, mental health and alexithymia in incarcerated young offenders, International Journal of Speech-Language Pathology, DOI: 10.3109/17549507.2015.1081291 To link to this article: http://dx.doi.org/10.3109/17549507.2015.1081291

Published online: 15 Oct 2015.

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Date: 20 October 2015, At: 02:42

International Journal of Speech-Language Pathology, 2015; Early Online: 1–12

Language functioning, mental health and alexithymia in incarcerated young offenders

PAMELA C. SNOW1, MARY WOODWARD2, MONIQUE MATHIS3 & MARTINE B. POWELL4 Psychology & Psychiatry, Monash University, Bendigo Regional Clinical School, Bendigo, Australia, 2Speak Your Mind Services, Neutral Bay, Sydney, Australia, 3NSW Juvenile Justice, Western Region, Wagga Wagga, Australia, and 4School of Psychology, Deakin University, Melbourne, Australia

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Abstract Purpose: Previous studies describe high rates of language impairment in young offenders; however, important correlates such as mental health status and alexithymia have received little attention. Method: This study describes a cross-sectional study of the language, emotion recognition and mental health of 100 young people completing custodial sentences in New South Wales (Australia). The sample comprised 70 young people from nonindigenous backgrounds (n ¼ 60 male) and 30 from indigenous backgrounds (n ¼ 25 male). The mean age of the sample was 17.1 years. It was hypothesized that, in addition to elevated rates of language impairment, alexithymia would be overrepresented in this group. It was further predicted that impoverished language skills would contribute to alexithymia scores. Result: Only a quarter of the sample overall achieved Clinical Evaluation of Language Fundamentals (CELF-4) Core Language Scores in the expected range; rates of language impairment were higher in indigenous males than in nonindigenous males and in the females. Alexithymia was present in 59% of the sample, but appeared to be associated with poor mental health, rather than with language impairment. Conclusion: Interventions for young offenders (e.g. psychological counselling, restorative justice conferencing) should be framed around these difficulties. Validated language measures for use with young indigenous offenders are needed.

Keywords: Young offenders, language, alexithymia

Introduction Young people who become involved with youth justice services are characterized by a range of developmental and psychiatric risk profiles. Prominent among these are histories of childhood conduct disorders, attentional disorders, low academic achievement and both low and high prevalence mental health conditions (Fougere, Thomas, & Daffern, 2012). In recent years, a growing body of evidence has emerged that also identifies young offenders as a group that is high-risk for previously undiagnosed expressive and receptive oral language difficulties (Blanton & Dagenais, 2007; Bryan, 2004; Bryan, Freer, & Furlong, 2007; LaVigne & Rybroek, 2010, 2013; Sanger, Creswell, Dworak, & Schultz, 2000; Sanger, Moore-Browne, Montgomery, & Larson, 2002; Sanger, MooreBrowne, Montgomery, Rezac, & Keller, 2003; Snow & Powell, 2004, 2005, 2008, 2011a). Such difficulties appear to span all aspects of expressive

and receptive language skills, resulting in reduced vocabulary, syntactic complexity, narrative skill and ability to process figurative language. In this paper, we examine links between language difficulties and two important comorbidities in youth offender populations: alexithymia (difficulty identifying and describing affective states) and mental health problems. In addition to poor performance on standardized language measures, young offenders have also been shown to display poor narrative language skill (Snow & Powell, 2005). Narrative refers to a speaker’s ability to ‘‘tell a story’’ and to do so using a logical, sequential order, linking characters and events via appropriate use of cohesive devices (Paul & Norbury, 2012). Narratives are an important tool of social discourse, as they facilitate connections between speakers and a sense of shared knowledge and understanding of their immediate worlds (Paul & Norbury, 2012). However, they also have a special forensic significance, as narratives are the means by

Correspondence: Professor Pamela C. Snow, Monash University, Psychology & Psychiatry, Bendigo Regional Clinical School, PO Box 666, Bendigo, 3552 Australia. Email: [email protected] ISSN 1754-9507 print/ISSN 1754-9515 online ß 2015 The Speech Pathology Association of Australia Limited Published by Taylor & Francis DOI: 10.3109/17549507.2015.1081291


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P. C. Snow et al.

which (a) a suspect provides an account of his actions to police, (b) legal counsel is briefed about the matters pertaining to charges, and (c) questions may need to be responded to in court (Snow & Powell, 2005). As such, narrative production draws heavily on a wide range of language skills (vocabulary, sentence structure, use of cohesive devices to reduce ambiguity) and social cognition skills, e.g. judgement about prior listener knowledge, monitoring listener reaction for signs of disinterest and/or confusion, and the ability to detect and correct one’s own errors. In many cases, narratives are coconstructed as part of conversations, and so also draw on turn-taking skills (Paul & Norbury, 2012). Its sensitivity to a wide range of linguistic and cognitive difficulties has led to narrative discourse being described as a ‘‘canary in the coalmine’’ with respect to language function (Snow & Powell, 2008), i.e. its integrity can be compromised for a wide range of reasons. Understanding language impairments in young offenders is important for a number of reasons. Most notably, these usually go undetected; hence, service providers in correctional facilities are frequently unaware of the nature and implications of such impairments (Caire, 2013; Snow & Powell, 2011a). It has been observed that language difficulties in this population often ‘‘masquerade’’ as behavioural noncompliance, rudeness and/or indifference (Snow & Powell, 2011a,b), thus standing to further disadvantage the young person in his/her passage through the justice system. Second, language skills contribute to the success of forensic interviews, whether with police or legal counsel (Snow & Powell, 2004), and are also critical for engagement in therapeutic interventions, e.g. deriving benefit from psychological therapies such as cognitive behavioural therapy (CBT) requires the use of language to ‘‘think about thinking’’. Third, there is a growing trend towards diversional approaches such as restorative conferencing with young offenders, as an alternative to more traditional, punitive approaches to justice administration. Restorative conferencing places significant demands, however, on a young person’s receptive and expressive language skills and may be adversely affected by difficulties accessing vocabulary and formulating narratives that are judged as complete and authentic by their victims. Of particular note in the context of restorative conferencing is the need to use and understand words pertaining to emotion, one’s own and those of others. Although these issues do not appear to have been empirically studied, they have been the subject of recent speculation in the criminology (e.g. Hayes & Snow, 2013) and speech-language pathology (Snow & Sanger, 2011) literature. Finally, language difficulties are likely to interfere with engagement in verbally mediated interventions such as psychological counselling (Snow & Powell, 2011b).

Another factor that can make engagement with therapeutic interventions difficult in this population is alexithymia. According to Taylor (2000), the salient features of this construct are: (1) difficulty identifying and describing subjective feelings; (2) difficulty distinguishing between feelings and the bodily sensations of emotional arousal; (3) constricted imaginal capacities, as evidenced by a paucity of fantasies; and (4) an externally oriented cognitive style. Alexithymia has been described in a wide range of psychiatric populations and has also been studied in community samples. Joukamaa et al. (2007) studied alexithymia in a sample of over 6000 adolescents who were part of a longitudinal birth cohort study. They reported that the prevalence of alexithymia among 15–16-year olds was very similar to previously reported adult rates (9–17% among men and 5–10% among women), although the scores of males were higher (i.e. poorer). Alexithymia was associated with adverse early childhood experiences such as low maternal education level and family breakdown. Alexithymia has also been studied in young offender populations, with Zimmerman (2006) identifying this in 47.2% of young male offenders, with particular difficulties evident with the identification of feelings. Zimmerman noted that this prevalence is similar to rates that have been reported in studies of patients with psychiatric disorders. More recently, Manninen, Therman, Suvisaari, Ebeling, Moilanen, Huttunen, et al. (2011) examined alexithymic symptoms in a sample of 47 adolescents identified on the basis of severe behavioural disorders and described significantly higher rates compared to a control sample of non-behaviourally disturbed adolescents. Similar findings were confirmed by Pihet, Combremont, Suter, and Stephan (2012) in their community sample of high-risk adolescents. There are close developmental links between the emergence of language, empathy, social cognition and Theory of Mind (ToM; Cohen, 2002; Happe´ & Frith, 2014), all of which are relevant to the identification and labelling of mental states—in oneself and in others. Dunn (1991) observed that ‘‘Differences between families in the frequency and extent of discussion of others’ feelings, motives and behaviour are striking’’ (p. 111). Families who do discuss and explain people’s feelings and emotions in a co-operative manner, and who ‘‘debrief’’ about feelings and emotional reactions resulting from sibling conflict appear to promote an earlier emergence of ToM than those families where coercive and punitive parenting styles are used (Astington & Barriault, 2001). This is significant inasmuch as these pro-social skills probably also confer a number of protective benefits on children, such as awareness of their own affective state and respect for the thoughts and feelings of others, through the fostering of trusting relationships with key adults.


Language and mental health in young offenders

Such patterns of parenting and family life are negatively correlated with psychosocial risk in general and with child abuse/youth justice involvement in particular. Conversely, child abuse and neglect are both associated with impoverished language development (Paul & Norbury 2012; Snow, 2009), thus adding additional weight to the importance of studying language development alongside the development of broader social cognition skills, such as recognition and labelling of affective states in oneself and in others. In addition to evidence that young offenders face increased risks for language impairment and alexithymia, relative to non-offending peers, previous research has shown high rates of both low and high prevalence psychiatric diagnoses in youth offenders (Grisso, 1999; Ryan & Redding, 2004); however, Snow and Powell (2011a) did not find that elevated scores on the Depression, Anxiety and Stress Scale (DASS; Lovibond & Lovibond, 1995) were significantly correlated with scores on standardized measures of expressive and receptive language skills. Hence, we know that young offenders are (a) more prone to mental health difficulties, (b) display high rates of unidentified expressive and receptive language difficulties and (c) are more prone to alexithymia than their non-offending peers. However, it is not known to what extent, and in which ways, these phenomena are linked in youth justice populations. This is significant because difficulty identifying, labelling and discussing emotions, (their own and those of others) would be expected to hinder engagement in verbally mediated psychological therapies and restorative justice interventions. Hence, for the first time in this study, measures of oral language skill, mental health functioning and alexithymia were included, in an effort to understand the ways in which these constructs interact in a youth justice sample. Although language skills in youth offender samples have been well-described in previous studies, two significant oversights in Australia persist: (i) the failure to include sub-groups of young offenders from indigenous (Aboriginal and Torres Strait Islander; ATSI) backgrounds and (ii) the absence of data on young female offenders. Current evidence indicates that, although young people from ATSI backgrounds represent only 3% of the Australian population, they represent some 38% of youth offender statistics and this rate is even higher in some jurisdictions (Australian Institute of Health and Welfare, AIHW; 2014a). In reviewing factors that contribute to poor educational outcomes for Australian indigenous students, Prior (2013, p. 127) observed that: There is evidence to show that more than 50% of Indigenous children, whether urban, rural or remote, are significantly behind non-Indigenous children in the

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levels of English language competence expected for their age when they first enter school.

For these reasons, a sub-group of young ATSI offenders was specifically recruited for the current study. The almost exclusive emphasis on young males in the youth justice system in previous studies, with the exception of a small body of US research on young females (e.g. Sanger, Ritzman, Schaefer, & Belau, 2008), was also addressed in this study, through the inclusion of a female sub-group. The principle aim of this study was to examine the prevalence of alexithymia in a sample of incarcerated young offenders and to determine the extent to which expressive and receptive oral language difficulties contribute to the expression of this disorder in young offenders. It was hypothesized that, in addition to their low scores on measures of oral language competence and higher than average rates of mental health difficulties, young offenders would display high rates of alexithymia. Further, it was hypothesized that mental health problems and poor language skills would make a significant contribution to the presence of alexithymia in this group. Subsidiary aims of the study were to examine the language, mental health and emotion recognition profiles of young offenders from indigenous backgrounds and also to explore the possible role of gender with respect to these constructs. As there is a dearth of literature on which to draw to form hypotheses with respect to indigenous status and gender in youth offender populations, no explicit predictions were made about the impact of these independent variables on the measures of interest. Method This study was approved by the Monash University Human Research Ethics Committee and also by the New South Wales (NSW) Office of the Attorney General. Participants One hundred young people completing custodial sentences in the New South Wales Juvenile Justice system were recruited into the study over a 6-month period in 2013–2014. Because no past studies have examined the language skills of young people from ATSI backgrounds and this group is significantly over-represented in Australian youth justice statistics (AIHW, 2014a), we specifically recruited a subgroup (n ¼ 30) of such young people. To control for Standard Australian English (SAE) exposure, however, we recruited only young ATSI offenders who had grown up entirely in urban settings. This was considered important because the formal language measures employed have not been specifically standardized for use with young people from ATSI backgrounds and Aboriginal English, although a


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P. C. Snow et al.

dialect of SAE, differs significantly from SAE with respect to phonological, semantic and syntactic features (Eades, 2013). Other inclusion criteria were as follows: having been sentenced as a result of a court conviction (i.e. not being on remand, awaiting a court appearance); no confirmed diagnosis of intellectual disability (given that intellectual disability is almost invariably associated with compromised expressive and/or receptive language skills in some form); no acute mental state alterations (e.g. acute anxiety or psychosis) that would compromise capacity to engage in assessment; the majority of schooling having been completed in an English-speaking country. The majority (85%) of the sample was male and 70 were young people from non-ATSI backgrounds. Of the 30 who were from ATSI backgrounds, 25 were male. The mean age of the group as a whole was 17.1 years (SD ¼ 1.4; range ¼ 15–20). The mean age of the non-ATSI group (17.2; SD ¼ 1.5) was significantly older than that of the ATSI subgroup (16.7; SD ¼ 1.2; t ¼ 1.7; p ¼ 0.04). Fifteen participants were female, of whom five were from ATSI backgrounds. There was no difference between males and females with respect to age. Very few (15%) participants had undertaken any vocational training and only eight had progressed in formal schooling beyond Year 10.y Just over a third of the sample (34%) had completed no more than Year 8 at school (in fact eight had not progressed beyond primary school). Forty-four per cent reported special school attendance of some form (usually a special behavioural school setting) and 87% reported a history of school suspension and/or expulsion. When specifically asked (in the context of a structured interview) about prior diagnoses, 32 indicated they had had a blow to the head resulting in loss of consciousness, three reported hearing impairment and one reported an autism spectrum diagnosis. Most (91%) answered ‘‘no’’ to a diagnosis of Foetal Alcohol Syndrome, however nine indicated that they were unsure as to whether such a diagnosis had been made. Twenty-eight participants reported having had a period of Out of Home Care (OHC) and the age at which such placements first occurred was roughly evenly split between before age 12 and after age 12. When asked about past history of speech, language and communication needs, eight responded that they were aware of such needs. Past histories of depression were self-reported by 17 participants, anxiety by 18 and psychotic illness by eight (drug-induced psychosis in all cases). y Formal schooling extends over a 13-year period in Australia. In New South Wales this comprises 7 years of primary (elementary) schooling and 6 years of secondary schooling. Students typically turn 13 in the year that they commence secondary school (Year 7). With respect to offending history, data were provided by NSW Juvenile Justice on Australian

Table I. Australia and New Zealand Standard Offence Classification of most serious offence types frequency (n ¼ 100). ASOC offence type

Frequency (¼%)

Homicide and related offences Manslaughter Driving causing death Serious assault resulting in injury Serious assault not resulting in injury Common assault Stalking Other acts intended to cause injury Aggravated sexual assault Aggravated drink driving offences Dangerous or negligent operation of a vehicle Abduction and kidnapping Aggravated robbery Non-aggravated robbery Unlawful entry with intent to burgle Total

1 1 1 20 24 9 1 1 6 2 2 1 14 2 15 100

and New Zealand Standard Offence Classification (ANZSOC) codes for each participant’s most serious conviction pertaining to the current period of incarceration (Australian Bureau of Statistics, 2011). A total of 15 different ANZSOC codes were represented, and these are listed in Table I. As may be seen, acts of interpersonal violence dominate the most serious convictions in the sample. Recruitment and assessment was conducted by the same Speech Language Pathologist (SLP) in all cases (MW). Inclusion and exclusion criteria were provided to Juvenile Justice key-workers, who made the initial approach to the young person to gauge interest and willingness to participate. Those who consented to further contact were then approached by the SLP. Following the collection of biographical and demographic information via a structured interview, the measures below were administered. Where indicated on logistical or clinical grounds, assessment was conducted over more than one session and rest breaks were provided as needed. No incentives were offered to young people who were approached to take part in the study. Measures Depression, Anxiety and Stress scale (DASS). The Depression, Anxiety and Stress Scale (DASS, Lovibond & Lovibond, 1995) was used to detect high-prevalence mental health problems and quantify these as possible comorbidities with language impairments and alexithymia. This tool provides separate scores for depression, anxiety and stress, which the individual rates on a series of 4-point ordinal scales. Scores on each parameter can be categorized to reflect no abnormality, mild, moderate, severe or very severe dysfunction. The DASS has been shown to have robust psychometric properties (e.g. Antony, Bieling, Cox, Enns, & Swinson, 1998).



Clinical Evaluation of Language Fundamentals–4th edition, Australian standardization (CELF-4). The Core Language Score was derived from four subtests of the Clinical Evaluation of Language Fundamentals, 4th edition (CELF-4; Australian standardization; Semel, Wiig, & Secord, 2003). These are: Recalling Sentences, Formulated Sentences, Word Classes (Receptive and Expressive) and Word Definitions. The CELF-4 provides detailed, norm-referenced data and is widely used in Australia and overseas, in both clinical and research contexts, as an accepted measure to determine the presence of a clinical language disorder and entitlement to specialist services (e.g. speech-language pathology services in schools). Test of Language Competence–Expanded (TLC-E). Three sub-tests of the TLC-E were included as a measure of figurative and idiomatic use of language, in contrast to the CELF-4, which is commonly regarded as a measure of ‘‘structural’’ aspects of language (e.g. vocabulary and syntax use and understanding). The test’s psychometric properties are outlined in the technical manual (Wiig & Secord, 1989). Sub-test 1 (Ambiguous Sentences) requires the interpretation of sentences with lexical, surface structural and underlying structural ambiguities, for which two alternative meanings are identified and explained by the participant, e.g. ‘‘John was looking up the street’’—he was either standing on the footpath looking up the street or he was looking up the street in a map. Sub-test 2 (Listening Comprehension: Making Inferences) requires the drawing of inferences based on incomplete information which is presented as an event chain, by choosing two plausible story outcomes from four choices. Sub-test 4 (Figurative Language) requires the participant to interpret metaphoric expressions, by selecting an alternative from a choice of four options, e.g. recognizing that ‘‘There is rough sailing ahead of us’’ has a non-literal meaning concerning difficult times. In each of these sub-tests, the participant both heard and saw the printed stimuli, which were placed in clear view and read aloud by the examiner. The remaining TLC-E sub-test, Oral Expression: Recreating Speech Acts measures the ability to infer protagonists’ intentions as presented by a drawing. As we tapped a similar social cognition skill via our narrative language task, we decided to reduce assessment time by not including both.

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setting, an initiating event, an internal response, a plan, an attempt, a direct consequence and a resolution. A scoring template developed by Snow and Powell (2005) was used to measure the quantitative and qualitative aspects of the narratives derived from the audiotaped and transcribed samples. This stimulus has been used in previous studies examining narrative language skills in young offenders (Snow & Powell, 2005,2008). Inter-rater reliability and scoring accuracy checks were conducted on a random sample of 10% of standardized and narrative test scores before data analysis was undertaken. Toronto Alexithymia Scale (TAS-20) The TAS-20 (Bagby, Parker & Taylor, 1994a; Bagby, Taylor, & Parker, 1994b) is a widely used self-report measure of alexithymia and comprises three sub-scales: (1) Difficulty Describing Feelings, (2) Difficulty Identifying Feelings and (3) Externally-Oriented Thinking. Respondents are asked to rate their agreement with statements such as ‘‘When I’m upset, I don’t know if I’m sad, frightened or angry’’. The TAS-20 has been shown to have robust psychometric properties, with respect to internal consistency (Cronbach’s alpha ¼ 0.81) and test–retest reliability (0.77, p50.01) and both convergent and concurrent validity. It has been shown to be stable and replicable across clinical and non-clinical populations (Bagby et al., 1994). It has also been shown to be valid for use with indigenous respondents (Parker, Shaughnessy, Wood, Majeski, & Eastabrook, 2005). Kaufman Brief Intelligence Test (K-BIT2)— Matrices sub-test The Matrices sub-test of the Kaufman Brief Intelligence Test, 2nd edition (Kaufman & Kaufman, 2004) was employed as a measure of non-verbal intelligence, so that language profiles could be examined against an estimate of IQ. This test is designed to measure fluid intelligence, i.e. the ability to problem-solve through the perception of non-verbal relationships and by completing nonverbal analogies. Result Table II displays the descriptive statistics pertaining to the mental health, language, non-verbal IQ and alexithymia measures employed.

Narrative language task The ‘‘Flowerpot Incident’’ (see Appendix) cartoon stimulus was used to elicit a spoken narrative from participants. This six-frame stimulus depicts an incident that follows a story grammar structure (Hedberg & Stoel-Gammon, 1986), i.e. there is a

Language skills Only a little over a quarter (n ¼ 26) of the sample overall had CELF-4 Core Language Scores in the expected range (86–114) and the largest single group (n ¼ 40) had Core Language Scores in the

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P. C. Snow et al.

Table II. Descriptive statistics for the sample as a whole on mental health, standardized language, non-verbal IQ and alexithymia scales. Mean


DASS Depression sub-scale DASS Anxiety sub-scale DASS Stress sub-scale CELF4 Recalling Sentences sub-scale CELF4 Formulated Sentences sub-scale CELF4 Word Classes (total) sub-scale CELF4 Word Definitions sub-scale CELF4 Core Language Score TLC-E Ambiguous Sentences sub-scale TLC-E Listening Comprehension sub-scale TLC-E Figurative Language sub-scale Narrative Language Global score Composite Language score TAS-20 K-BIT2

8.5 6.3 13.3 5.9 6.4 5.3 5.0 73.0 5.0 5.2 4.9 6.9 94.7 55.0 86.5

SD 9.7 6.9 9.9 2.8 3.2 3.2 3.2 17.2 2.4 2.2 2.0 2.0 22.3 10.7 15.7

very low/severe range (70 and below). The remainder of the group fell in the marginal–mild impairment range (78–85; n ¼ 18) and the low–moderately impaired range (71–77; n ¼ 16). In a previous study (Snow & Powell, 2011a), we operationally defined ‘‘language impairment’’ as scores that were below two standard deviations below the mean on both the CELF-4 Core Language Score and two of the three TLC-E subtests. Using this rather stringent criterion, 37% of the current sample was classified as language impaired. Because this is the first study to employ the CELF-4 with a sub-group of young offenders from ATSI backgrounds, their language scores were compared with those of the non-ATSI members of the group. These results are shown in Table III. As may be seen in this table, although the ATSI subgroup’s scores were lower than those of the nonATSI sub-group on all except one measure (TLC-E Listening Comprehension, on which mean scores were the same), in general the scores of the two subgroups did not differ significantly. Bonferroni adjustment for multiple comparisons (Keppel, 1991) yielded a modified alpha of p50.0055 and no comparisons were significant at this level. However, when Core Language Score sub-groups were considered as a function of ATSI status, it was evident that a higher proportion of the latter group had scores outside the expected range. These findings are summarized in Table IV. As may be seen, while 30% of the non-ATSI offenders had scores in the average range on this measure, this was the case for only 16% of those in the ATSI subgroup. The small sub-group of ATSI females (n ¼ 5) were distributed across the severity ranges, with two in the average range, one marginal and two in the very low range. Because of the cultural and gender variation present in this sample, language impairment was considered separately for (i) non-ATSI males, (ii) ATSI males and (iii) females. Using Snow and Powell’s (2011) operational definition (outlined

above), language impairment was present in 36.7%, 44% and 26.7% of these sub-groups, respectively. Because of small numbers (n ¼ 5) in the ‘‘ATSI and female’’ cell, no further analysis was conducted on that sub-group. Other findings pertaining to scores as a function of gender are reported below. Mental health status Thirty-one per cent of participants had DASS Depression sub-scale scores that were in a clinical range and scores in a clinical range occurred for 26% of the group on the Anxiety sub-scale and 40% on the Stress sub-scale. DASS scores for the ATSI and non-ATSI sub-groups are shown in Table V. As may be seen in this table, scores of the ATSI group was higher (i.e. poorer) on all three domains and also on the total score. As a Kolmogorov-Smirnov test for normality was significant (p ¼ 0.000), nonparametric analysis was performed. No significant between-groups differences were found on MannWhitney U-tests on any DASS sub-scale or on the total scores (Depression: U ¼ 929.5, p ¼ 0.36; Anxiety: U ¼ 999.5, p ¼ 0.68; Stress: U ¼ 834, p ¼ 0.10). The scores reported here sit between those derived from a community sample of 2914 Australian adults and those derived from a clinical sample (Lovibond & Lovibond, 1995). Alexithymia The mean TAS-20 score for the group as a whole was 55.0 (SD ¼ 10.7). When scores were examined as a function of ATSI status, a significant difference was not identified (ATSI, M ¼ 54.3, SD ¼ 10.4; non-ATSI, M ¼ 55.3; SD ¼ 10.9; t ¼ 4.2, p ¼ 0.675 2-tailed). Using the published TAS-20 suggested categorical cut-offs (Bagby et al., 1994), 41 participants were judged to not display alexithymia, 29 were classified as having ‘‘possible alexithymia’’ and 30 as reaching the alexithymia cut-off. Scores were then converted to binary categories, ‘‘alexithymia likely’’ vs ‘‘alexithymia unlikely’’ and were considered as a function of ATSI status. A sub-group by alexithymia status interaction was not found (2 ¼ 1.4, p ¼ 0.23), so the scores of the sample were considered as a whole. Because the language measures (CELF-4 Core Language Score, TLC-E three sub-test scores and narrative language global score) were all intercorrelated (see Table VI), a Composite Language Score was created for the purposes of analysis. The Composite Language Score was the sum of the CELF-4 Core Language Score, the three TLC-E sub-tests and the Narrative Discourse story grammar total score. There was no difference between the ATSI and non-ATSI sub-group means on this composite measure (t ¼ 1.43, p ¼ 0.15). The following were considered as appropriate independent variables in a generalized linear


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Table III. Language measure scores as a function of Aboriginal and Torres Strait Islander status: Descriptive and inferential statistics. Language measure

ATSI status

n

CELF-4 Recalling Sentences sub-scale

Non ATSI ATSI Non ATSI ATSI Non ATSI ATSI Non ATSI ATSI Non ATSI ATSI Non ATSI ATSI Non ATSI ATSI Non ATSI ATSI Non ATSI ATSI Non ATSI ATSI

70 30 70 30 70 30 70 30 70 30 70 30 70 30 70 30 70 30 70 30

CELF-4 Formulated Sentences sub-scale CELF-4 Word Classes (total) sub-scale CELF-4 Word Definitions sub-scale CELF-4 Core Language Score TLC-E sub-test 1 Ambiguous Sentences scaled score TLC-E sub-test 2 Listening Comprehension scaled score TLC-E sub-test 4 Figurative Language scaled score Narrative Language Global score


Composite Language Score

M 5.9 5.8 7.0 5.4 5.7 4.6 5.3 4.5 74.8 68.7 5.1 4.6 5.2 5.2 4.9 4.6 6.95 6.93 96.8 89.9

SD 3.0 2.6 3.1 3.3 3.3 2.8 3.3 2.8 16.9 17.3 2.5 2.2 2.2 2.3 2.0 1.8 1.7 2.4 21.8 23.0

t

p*

0.17

0.44

2.2

0.01

1.6

0.052

1.2

0.12

1.6

0.055

0.78

0.22

0.06

0.46

0.84

0.40

0.76

0.45

1.4

0.15

*one-tailed t-tests reported (modified ¼ 0.0055). CELF-4, Clinical Evaluation of Language Fundamentals (4th edition); TLC-E, Test of language Competence, Expanded edition.

Table IV. Clinical Evaluation of Language Fundamentals-4 Core Language score severity ranges as a function of Aboriginal and Torres Strait Islander status. ATSI status CELF-4 Core Language severity sub-group

Non-ATSI

ATSI

Total

Average (86–114) Marginal/Borderline/Mild (78–85) Low range/Moderate (71–77) Very low range/Severe (70 and below) Total

21 (30%) 9 (13%) 13 (18.5%) 27 (38.5%) 70

5 (16.7%) 9 (30%) 3 (10%) 13 (43.3%) 30

26 18 16 40 100

Table V. Depression, anxiety and stress scores as a function of Aboriginal and Torres Strait Islander status.

DASS Depression score DASS Anxiety score DASS Stress score

ATSI status

n

M

SD

Non ATSI ATSI Non ATSI ATSI Non ATSI ATSI

70 30 70 30 70 30

7.9 10.2 6.0 7.3 12.1 16.0

9.5 10.3 6.5 7.8 9.3 11.0

regression to determine the extent to which alexithymia scores are contributed to by language functioning, mental health and key demographic variables: Composite Language Score, DASS Total Score, ATSI status and gender. Initial consideration was given to K-BIT2 scores; however, this variable was found to be significantly correlated with CELF4 Core Language Scores (Pearson’s r ¼ 0.60, p ¼ 0.000) and so it was excluded from the proposed regression model. As may be seen in Table VII, however, with the exception of DASS scores, there were no significant correlations between potential predictor variables and the criterion variable, TAS20 scores. For this reason, a regression analysis was not performed and results are reported instead as descriptive data and correlations. Results pertaining to key language, alexithymia and mental health measures as a function of gender

are displayed in Table VIII. Because these data were considered exploratory and did not have specific hypotheses attached, no adjustment to alpha for multiple comparisons was made. As may be seen in this table, the female sub-group’s language scores were higher (i.e. better) on all measures compared with those of the males; however, none of these differences was statistically significant. Results suggest that alexithymia and mental health scores in the female sub-group were significantly poorer than those of the males. As noted above, rates of language impairment were lower in the female sub-group than in the two male sub-groups. In summary, results show that only a quarter (26%) of the sample overall performed in the average range on the CELF-4 Core Language Score. Using the same, conservative cut-off as was used in a previous, similar study (Snow & Powell, 2011a), 37% of the sample overall was classified as ‘‘language impaired’’, although there was a marked spike in language impairment classification for the ATSI males (44%). Where language difficulties were found, these were evident across the full range of expressive and receptive skills and a smaller proportion of ATSI participants had CELF-4 Core Language Scores in the average range. Similarly, the females in the sample appeared to score slightly better on language measures than the males;

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P. C. Snow et al.

Table VI. Language measures: Inter-correlations. Correlations

CELF-4 core language score

CELF-4 Core Language Score TLC-E Total (3 sub-tests) Narrative discourse story grammar adequacy score

Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) n Pearson correlation Sig. (2-tailed) n

100 0.801** 0.000 100 0.279** 0.005 100

TLC-E total (3 sub-tests)

Narrative discourse story grammar adequacy score

0.801** 0.000 100

0.279** 0.005 100 0.315** 0.001 100

100 0.315** 0.001 100

100

**Correlation is significant at the 0.01 level (2-tailed). CELF-4, Clinical Evaluation of Language Fundamentals (4th edition); TLC-E, Test of Language Competence, Expanded edition.


Table VII. Correlation matrix: Depression, Anxiety and Stress Scale, Composite Language Score, Kaufman Brief Intelligence Test (2nd edition) and Toronto Alexithymia Scale-20 scores. Composite language score Composite language score DASS total score Toronto Alexithymia Scale (TAS-20) score K-BIT matrices scaled score

Pearson correlation Sig. (2-tailed) n Pearson correlation Sig. (2-tailed) n Pearson correlation Sig. (2-tailed) n Pearson correlation Sig. (2-tailed) n

100 0.102 0.313 100 0.069 0.495 100 0.627** 0.000 100

DASS total score

Toronto Alexithymia Scale (TAS-20) score

K-BIT matrices scaled score

0.102 0.313 100

0.069 0.495 100 0.621** 0.000 100

0.627** 0.000 100 0.034 0.735 100 0.023 0.824 100

100 0.621** 0.000 100 0.034 0.735 100

100 0.023 0.824 100

100

**Correlation is significant at the 0.01 level (2-tailed).

Table VIII. Descriptive and inferential statistics pertaining to key measures as a function of gender.

CELF-4 Core Language Score TLC-E Total (3 subtests) Narrative discourse Story Grammar adequacy score Toronto Alexithymia Scale (TAS-20) score DASS Depression score DASS Anxiety score DASS Stress score

Gender

n

M

SD

t

p

Male Female Male Female Male Female Male Female Male Female Male Female Male Female

85 15 85 15 85 15 85 15 85 15 85 15 85 15

72.4 75.7 14.6 16.5 6.8 7.1 54.2 59.5 7.5 14.5 5.9 8.7 12.4 18.5

17.2 17.4 5.0 6.4 2.0 1.8 10.7 9.8 9.1 11.6 6.5 9.0 9.8 9.3

0.69

0.48

1.2

0.22

0.58

0.56

1.8

0.074

2.6

0.01*

1.4

0.15

2.5

0.03*

2-tailed p-values are reported *p50.05. CELF-4, Clinical Evaluation of Language Fundamentals (4th edition); TLC-E, Test of Language Competence, Expanded edition; DASS, Depression, Anxiety and Stress Scale.

however, these differences were not statistically significant and language impairment was present in more than a quarter of this sub-group. Overall, depression, anxiety and stress scores were elevated compared to those of an Australian community sample, although not severely so, and sub-group differences as a function of ATSI status were not found. However, it would appear that the young

females in the sample had particularly high depression and stress scores. Alexithymia was considered at least ‘‘possible’’ in 59% of the sample; however, this again did not differ as a function of ATSI status, but gender may be a significant influence on this variable, as it would appear that scores of the female sub-group were higher (i.e. worse) than those of the males. It was not


possible to perform a regression analysis to examine the contribution of language skills to alexithymia, as language variables were not found to be significantly correlated with TAS-20 scores.


Discussion As expected, language skills of the group were poor. Only a quarter had oral language skills (as measured by the CELF-4 Core Language Score (Semel et al., 2003)) in the expected range. There were no significant differences between the language skills of young offenders from ATSI backgrounds and their non-ATSI peers on any of the language measures, although there were some trends that need to be considered further in future studies. Broad similarities between the two offender subgroups with respect to language skills are likely to reflect our decision to include only young people from ATSI backgrounds who had grown up in urban settings, in order to maximize their exposure to SAE. Aboriginal English is not, however, ‘‘one language’’ and future researchers will need to be cognisant of regional variations as well as the extent to which these young people are growing up in multilingual households, in which SAE may be their second, third or even fourth language (Eades, 2013). Malcolm (2011) has observed that ‘‘Standard English is but one element in the linguistic repertoire of most Indigenous people, yet Indigenous people’s entire linguistic competence is often judged on how well they use Standard English’’ (p. 194). Hence, it is not possible, on the basis of these findings, to rule out the reasonable hypothesis that young people from ATSI backgrounds have a more challenging passage through the justice system as a result of less well-developed receptive and expressive English language skills, irrespective of the presence of additional disadvantage associated with underlying oral language difficulties, as has been reported in non-ATSI young offender samples in Australia (see Snow & Powell, 2011a,b for discussion). This question of ‘‘difference vs deficit’’ will need to be considered closely in future studies and young ATSI people who come from rural and regional backgrounds (with and without youth justice involvement), where Aboriginal English is clearly dominant over SAE, will need to be recruited. Development of validated language assessment tools for this population will also be an important consideration. Using the same conservative operational definition of ‘‘language impairment’’ as was used in a previous, similar study of young custodial offenders (Snow & Powell, 2011a), 36.7% of the comparable sub-group (non-ATSI males) was so-classified, compared to 46% in the aforementioned study. Findings confirm those of previous workers (Blanton & Dagenais, 2007; Bryan, 2004; Bryan & Furlong, 2007; Snow & Powell, 2005,2008,2011a), indicating that language impairments are strongly over-

9

represented in youth justice populations. Although this is in part likely to reflect the mediating influence of socio-economic status (SES) on both language skills and risk for offending, it must be noted that SES alone does not account for very low scores in this population (see Snow & Powell, 2008, in which a similar SES comparison group was included). Only 26% of this sample overall scored in the expected range on the CELF-4 Core Language Score. This score encompasses everyday expressive and receptive language skills in key domains such as vocabulary and sentence structure which are essential to both the interpersonal and academic aspects of school success. The school careers of these participants were truncated and disrupted in the overwhelming majority of cases by suspensions and exclusions because of behavioural issues; however, the current findings are consistent with the view that unidentified language difficulties can contribute to everyday difficulties with social compliance and self-regulation (Cohen, 2001). Language difficulties have been described in youth offenders by a number of workers (e.g. Blanton & Dagenais, 2007; Bryan, 2004; Sanger, Moore-Brown, Magnuson, & Svoboda, 2001; Snow & Powell, 2011a); however, prevalence estimates vary quite widely. For example, Sanger at al. (2001) reported a prevalence rate of 19.1%, while Bryan (2004) reported a rate in excess of 60%. Such discrepancies reflect methodological differences between studies with respect to sample characteristics, measurement tools and operational definitions of ‘‘language impairment’’. While improved uniformity in the study of language skills of this group is desirable, the extant evidence is sufficient to indicate that language difficulties are common in this population, and need to be closely considered when psychological and educational interventions are being conceptualized and delivered, and should be factored into staff training in these settings. Approximately 17% of young offenders in Australia are female (AIHW, 2014b), so the proportion in this sample (15%) was broadly representative, although young ATSI females (n ¼ 5) were under-represented in this study. The fact that LI was present in 26.7% of the females overall indicates that further research is warranted with this important, but hitherto neglected sub-group, as this is still well above community estimates of language impairment in young people in Australia of 13% (McLeod & McKinnon, 2007). As hypothesized, alexithymia was strongly represented in this sample, with 59% of participants recording TAS-20 scores that placed them in either the ‘‘alexithymia likely’’ or ‘‘alexithymia possible’’ ranges. There is some indication that the TAS-20 scores of females were higher than those of males; however, the small sample size of the female subgroup (and the fact that it was significantly smaller than the male group) means that this possibility


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needs to be explored further in future studies. The high prevalence rates reported here are consistent with reports in comparable populations, (e.g. Manninen et al., 2011) and suggest that capacity to recognize and identify mental states is commonly compromised in this population. Notably, however, we did not find a significant correlation between language skills and alexithymia scores, even though scores were depressed and elevated, respectively, in the sample. An important variable that was significantly associated with alexithymia, however, was mental health, as represented by DASS scores. The cross-sectional nature of the study means that no causal inferences can be drawn about this relationship, but it needs to be borne in mind when implementing interventions such as psychotherapy and restorative conferencing. Our hypothesis that language functioning would contribute to alexithymia scores in a custodial youth justice sample was not supported. While alexithymia, mood disorders and language problems were all common features, alexithymia and language difficulties would appear to be comorbidities rather than correlates in this group. Knowing that such difficulties cluster in youth justice populations is important, as interventions offered to these young people typically operate in the interpersonal space, e.g. all forms of counselling, restorative justice conferencing and specific interventions such as anger management programs. Psychological therapies such as cognitive behaviour therapy are highly verbally mediated and require the individual to engage in conversation-based interventions that focus on talking about and reflecting on thoughts and feelings (Beck, 1995). The findings reported here indicate that practitioners should be aware of the particular difficulties young offenders face in (a) processing and using language and (b) identifying affective states and linking these to verbal labels. Both of these important processes are likely to be adversely affected by the presence of high-prevalence mental health problems such as depression, anxiety and stress. Apparent difficulties engaging with psychological interventions need to flag, therefore, that language skills and/or emotion recognition processes may require clinical investigation as part of individual treatment planning. Failure to recognize such possibilities carries the risk that low verbal engagement will be misconstrued as rudeness, disinterest and/or poor motivation to comply with interventions (Snow & Powell, 2011b). A number of limitations need to be borne in mind in interpreting these findings, most notably the fact that this is not a random sample of young offenders completing custodial sentences, so it is possible that young people who were particularly anxious about their communication skills either declined the invitation to take part or took this up at a greater rate than peers without such concerns. Female offenders (of both Caucasian and ATSI backgrounds) were

under-represented and neither close other nor selfreport data about communication competence was collected. Future workers should consider these factors. Another factor that should be considered by future workers is the optimal approach for assessing alexithymia in a population known to be high-risk for language difficulties. In this study, test items were read aloud to participants, in an effort to by-pass low literacy levels; however, it is recognized that this form of administration does tax auditory processing skills and so may compromise the test’s validity. An alternative, such as the Toronto Structured Interview for Alexithymia (Bagby, Taylor, Parker, & Dickens, 2006), may be more appropriate for use with this population.

Conclusions Compromised oral language skills are common in young offenders; however, in the absence of formal screening, these may not be recognized as such and so may not be appropriately considered in the context of therapeutic interventions. Language difficulties appear to be co-morbid (but not correlated) with compromised ability to identify and name one’s own affective states (alexithymia) and mental health problems such as depression and anxiety. This ‘‘trifecta’’ of difficulties needs to be considered when planning and delivering therapeutic interventions to young offenders. Language background also needs to be considered in the youth offender population, as indigenous status may add an additional layer of disadvantage with respect to the acquisition of mainstream competencies in expressive and receptive language skills. Language measures that are validated for use with young people from ATSI backgrounds need to be developed.

Acknowledgements The authors thank New South Wales Juvenile Justice (Department of the Attorney General) for assistance and funding to support this study. The assistance of the 100 young people who took part is particularly appreciated. We also wish to thank Ms Mabel KarWai Yan for her assistance with data entry and checking.

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juvenile and adult offenders and why it matters. Available online at: http://works.bepress.com/michele_lavigne/2, accessed 5 March 2015. Lavigne, M., & Van Rybroek, G. (2013) ‘He got in my face so I shot him’: How defendants’ language impairments impair Attorney–Client relationships. CUNY Law Review University of Wisconsin Legal Studies Research Paper No. 1228. Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression, Anxiety and Stress Scales. Sydney, Australia: Psychology Foundation. Malcolm, I. (2011). Issues in English language assessment of indigenous Australians. Language Assessment Quarterly, 8, 190–199. Manninen, M., Therman, S., Suvisaari, J., Ebeling, H., Moilanen, I., Huttunen, M., et al. (2011). Alexithymia is common among adolescents with severe disruptive behaviour. Journal of Nervous & Mental Disease, 199, 506–509. McLeod, S., & McKinnon, D. (2007). Prevalence of communication disorders compared with other learning needs in 14,500 primary and secondary school students. International Journal of Language and Communication Disorders, 37–59. Parker, J. D. A., Shaughnessy, P. A., Wood, L. M., Majeski, S. A., & Eastabrook, J. M. (2005). Cross-cultural alexithymia: Validity of the 20-item Toronto Alexithymia Scale in North American aboriginal populations. Journal of Psychosomatic Research, 58, 83–88. Paul, R., & Norbury, C. F. (2012). Language Disorders from Infancy through Adolescence (4th edition). St Louis, MS: Elsevier. Pihet, S., Combremont, M., Suter, M., & Stephan, P. (2012). Cognitive and emotional deficits associated with minor and serious delinquency in high-risk adolescents. Psychiatry, Psychology and Law, 19, 427–438. Prior, M. (2013). Language and literacy challenges for indigenous children in Australia. Australian Journal of Learning Disabilities, 18, 123–137. Ryan, E. P., & Redding, R. E. (2004). A review of mood disorders among juvenile offenders. Psychiatric Service, 55, 1397–1407. Sanger, D., Creswell, J. W., Dworak, J., & Schultz, l. (2000). Cultural analysis of communication behaviors among juveniles in a correctional facility. Journal of Communication Disorders, 33, 31–57. Sanger, D. D., Moore-Brown, B. J., Magnuson, G., & Svoboda, N. (2001). Prevalence of language problems among adolescent delinquents: A closer look. Communication Disorders Quarterly, 23, 17–26. Sanger, D. D., Moore-Brown, B. J., Montgomery, J. K., & Larson, V. L. (2002). Service delivery framework for adolescents with communication problems who are involved in violence. Journal of Communication Disorders, 35, 293–303. Sanger, D. D., Moore-Brown, B. J., Montgomery, J. K., Rezac, C., & Keller, H. (2003). Female incarcerated adolescents with language problems talk about their own communication behaviors and learning. Journal of Communication Disorders, 36, 465–486. Sanger, D., Ritzman, M., Schaefer, L., & Belau, D. (2008). Communication behaviors among incarcerated adolescent girls: A review of recent research. Women, Girls, and Criminal Justice, 9, 85–90. Semel, E., Wiig, W., & Secord, W. (2003). The Clinical Evaluation of Language Fundamentals–4th edition (Australian Standardisation). St Peters, NSW: Harcourt Assessment. Snow, P., & Powell, M. (2004). Interviewing juvenile offenders: The importance of oral language competence. Current Issues in Criminal Justice, 16, 220–225. Snow, P., & Powell, M. (2011a). Oral language competence in incarcerated young offenders: Links with offending severity, International Journal of Speech-Language Pathology, 13, 480–489. Snow, P. C. (2009). Child maltreatment, mental health and oral language competence: Inviting speech language pathology to the prevention table. International Journal of Speech Language Pathology, 11, 95–103.

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Appendix: Flowerpot Incident Cartoon stimulus

Adapted from Kossatz (1972). Reproduced with permission.

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