what is social communication disorder?PROFESSOR COURTENAY FRAZIER NORBURYUNIVERSITY COLLEGE LONDON

with thanks to… Surrey County Council and Surrey Schools – for taking part in the research reported here

Wellcome – for funding the Surrey Communication and Language in Education Study, in which CCC-2 data were obtained when children were in Year 1

The British Academy (mid-career Fellowship) – for funding the analyses of these data and the film that accompanies this slide share (https://www.youtube.com/RALLIcampaign )

Social (pragmatic) communication disorder: inclusion criteria

Persistent difficulties using verbal and non-verbal communication for social purposes: must meet all four of the following criteria:

1. Deficits using communication for social purposes in an appropriate manner given the context. Examples include greeting and sharing information.

2. Impairment of ability to adapt communication depending on the social context or the needs of the listener. Examples include talking differently to a child versus an adult, avoiding use of overly formal language.

3. Difficulties following rules for conversation and story-telling. Examples include poor turn-taking, repairing conversations (by rephrasing utterance or requesting clarification from the speaker) and knowing how to use verbal and non-verbal signals to regulate interaction.

4. Difficulties in understanding what is not explicitly stated or what is ambiguous. Examples include making inferences, use of non-literal language such as idioms, humour, metaphors, and multiple meanings. These may depend upon context for interpretation.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

The symptoms are not attributable to:

1. another medical or neurological condition

2. low abilities in structural aspects of language such as word structure and grammar

3. are not better explained by an autism spectrum disorder (i.e. occur in the absence of restricted and repetitive interests and behaviours)

4. intellectual disability or global developmental delay

5. any another mental disorder.

Social (pragmatic) communication disorder: exclusion criteria

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Similar to: Semantic – pragmatic disorder (Rapin & Allen, 1983)

◦ Original paper highlighting disproportionate difficulties with social use of language in verbose children◦ Seen as a symptom profile that most commonly occurred in children with autism spectrum conditions,

but could also occur in children with other developmental conditions◦ Note: social/pragmatic deficits are common in a range of conditions (ADHD, Williams syndrome, Fragile

X, hydrocephalus)

Pragmatic Language Impairment (Bishop & Norbury, 2002)◦ Attempt to identify a sub-group of children falling between autism and developmental language

disorder using a standard parent report measure◦ Children with PLI identified in this manner were social, but

◦ tended to use stereotyped language with abnormal intonation/prosody (now considered a repetitive behaviour in DSM-5)◦ many children with PLI also had deficits in structural aspects of language

Why is social (pragmatic) communication disorder important?

Social communication/pragmatic deficits are a significant risk factor for later social, emotional, and mental health disorders. These may include peer problems, social anxiety, conduct disorder, attention deficits, emotional dysregulation

◦ Skuse et al. (2009); Mok et al. (2014)

Social communication/pragmatic deficits are associated with academic difficulties, particularly reading comprehension

◦ Freed, Adams, & Lockton (2015)

NOTE: these studies did not apply DSM-5 exclusion criteria to participants. Many participants in these studies also had co-occurring deficits with structural aspects of language

Why is this new diagnosis controversial?

There are no gold standard assessments with which to diagnose social (pragmatic) communication disorder.

In fact, assessing social communication is very challenging given the dynamic nature of interaction (Adams, 2002)

Little evidence for validity of exclusion criteria – may prevent needy children from accessing services:

◦ Many children with social communication deficits have additional problems with vocabulary and grammar – structural language is important for understanding language in context

◦ Children with isolated social/pragmatic deficits appear to be quite rare

Norbury, CF. (2014). Social (Pragmatic) Communication Disorder– conceptualization, evidence and clinical implications. Journal of Child Psychology and Psychiatry, 55, 204-216..

Identifying children with social (pragmatic) communication disorder

Norbury, CF. (submitted). Prevalence and functional impact of Social (Pragmatic) Communication Disorder.

Language Scale comprised of:

Speech soundsSemanticsSyntaxCoherence

Social Communication Scale comprised of:

Use of ContextNon-verbal CommunicationInappropriate Initiation

Autism Symptom Scale comprised of:

InterestsSocial RelationsStereotyped language

Identifying children with social (pragmatic) communication disorder

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1810 20 30 40 50Pragmatic

Females Males95% CI Fit line

-1SD social communication scale

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children with social communication

deficits in absence of language impairment

3.4% of sample

• have elevated symptoms of ASD/ASD diagnosis

• tend to have peer problems

• limited academic deficits

cohort:

Teacher report of 323 children aged 5;1 to 6;8 years from population sample

correlation:

r = .85

Challenge with this approach: poor parent-teacher agreement

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2030

4050

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1810 20 30 40 50Pragmatic Teacher

Females Males95% CI Fit line

Sample:182 children with both parent and teacher report

Correlation:r = .48

Intra-class correlation co-efficient (measure of inter-rater reliability = .57, ‘fair’)

‘case’ agreement poor

summary (1) All communication is social! • Some children have noticeable and pronounced difficulties using language for social discourse and/or to resolve ambiguous utterances in speech or text

• Such ‘social communication’ disorders confer increased, and far reaching, risks for: ◦ Social, emotional and behavioural problems ◦ Poor mental health ◦ Peer problems ◦ Academic underachievement

summary (2) Specific inclusion/exclusion criteria for Social (Pragmatic) Communication Disorder, as defined by DSM-5, are currently unsupported by research ◦ children presenting with SPCD have language (vocabulary, grammar)

and cognitive deficits. The causal relations between these skill sets are currently unknown.

◦ Strong associations between ‘structural’ language, pragmatics and social behaviours makes it difficult to pull these apart

◦ SPCD may best be conceptualised as a Developmental Language Disorder. Specifiers may be used to characterise the nature of the language disorder at any given age

Intervention for SPCD Programme developed and evaluated by Dr Catherine Adams & Jacqueline Gaile at University of Manchester

Programme focuses on improving social communication by developing:

◦ Social understanding and social interaction◦ Non-verbal skills and pragmatic language◦ Language processing

Evaluation of programme promising, but challenged by lack of robust outcome measures of social communication

Social Communication Intervention Projecthttp://research.bmh.manchester.ac.uk/scip/

Adams, C., Lockton, E., Freed, J., Gaile, J., Earl, G., McBean, K., Nash, M., Green, J., Vail, A. & Law, J. (2012) International Journal of Language and Communication Disorders. 47, 3, p. 233-244 11 p.

summary (3) Improving social (pragmatic) communication is likely to require focus on multiple skills

◦ Social understanding◦ Structural language ◦ Experience and knowledge of social conventions

Access to services and support may be needed to avoid negative secondary consequences

Intervention should include opportunities to use new skills in everyday social contexts

Better outcome measures are needed, and likely require information from different sources

read more about it: Adams (2002). The assessment of language pragmatics. Journal of Child Psychology and Psychiatry, 43, 973-987.

Adams et al. (2012). The Social Communication Intervention Project… International Journal of Language and Communication Disorders. 47, 3, p. 233-244.

Baird & Norbury (2015). Social (pragmatic) communication disorders and autism spectrum disorder. Archives of Disease in Childhood, 101, 745-751.

Bishop (2003). The Children’s Communication Checklist-2. London: Pearson.

Bishop & Norbury (2002). Exploring the borderlands of autistic disorder and specific language impairment: a study using standardised diagnostic instruments. Journal of Child Psychology and Psychiatry, 43, 917–29.

Mok et al. (2014). Longitudinal trajectories of peer relations in children with specific language impairment. Journal of Child Psychology and Psychiatry, 55, 516–527.

Norbury (2014). Social (Pragmatic) Communication Disorder– conceptualization, evidence and clinical implications. Journal of Child Psychology and Psychiatry, 55, 204-216.

Norbury (submitted). Prevalence and functional impact of social communication disorder.

Rapin & Allen (1983). Developmental language disorders: Nosologic considerations, in U. Kirk (ed.), Neuropsychology of language, reading, and spelling (pp. 155–184). Academic Press.

Skuse et al. (2009). Social communication competence and functional adaptation in a general population of children: preliminary evidence for sex-by-verbal IQ differential risk. Journal of the American Academy of Child and Adolescent Psychiatry, 48 (2), 128-137.