Social (Pragmatic) Communication Disorder DSM-5 315.39 (F80.89)
DSM-5 Category: Neurodevelopmental Disorders
Introduction
Social (pragmatic) communication disorder (SCD) is a new diagnosis included in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013). The diagnosis is intended to recognize individuals who have significant problems in using verbal and nonverbal communication in social interactions. Such problems can interfere with interpersonal relationships, academic achievement and occupational performance. Problems with social communication are common in those with cognitive limitations, autism and related disorders and a variety of other psychiatric conditions, and are recognized in diagnostic criteria for these disorders in earlier editions of the DSM. Patients who are impaired in the use of language in social contexts but do not have autism, Asperger’s syndrome or cognitive limitations have been variously diagnosed and inconsistently treated, or often simply considered maladroit, eccentric or inattentive and not treated at all. Autistic spectrum disorder, mood and psychotic disorders and personality disorders can all be associated with impaired social communication, but have associated behavioral, thought or mood disturbances that facilitate an accurate diagnosis. The inability to communicate verbally or to understand and respond to nonverbal communication can be uniquely and devastatingly disabling to otherwise high-functioning individuals. The symptoms of SCD have often been lumped under the not- otherwise- specified category of pervasive developmental disorder, which has been clinically unhelpful and nosologically unsatisfying, and one of the goals of the DSM-5 has been the clearer definition of these incompletely-defined disorders.
The term “pragmatic” is used by language professionals to describe the communication skills that are needed in normal social intercourse and the rules that govern routine interpersonal interactions: pay at least some attention to the other person in a conversation, take turns in the conversation, do not interrupt the other speaker unless there is a very good reason, match language and volume to the situation and the listener, etc. People with this type of language impairment have difficulty using language in these social ways (semantic) or in understanding what is being said or connoted in social contexts (pragmatic). This led to the formerly-used rubric of semantic pragmatic disorder.
Semantic-Pragmatic Disorder / Pragmatic Language Impairment
Rapin and Allen proposed this term in 1983 to describe children with mild features of autism who manifested pathological talkativeness, deficient vocabulary, impaired ability to comprehend discourse, atypical choice of terms and inappropriate conversation skills (Rapin & Allen, 1983). Such children were later found to exhibit delayed language development and a variety of language errors, dislike or avoidance of eye contact, rigid habits and a shallower range of interests than normal, but sometimes striking abilities in certain areas such as mathematics or music. The degree of behavioral disturbance or restriction of interests was not as marked as in autism or Asperger’s syndrome, however.
Bishop and Norbury suggested that the disorder was not one of language but of information processing and response (2002). They found that children with semantic pragmatic disorder, later called pragmatic language impairment, had expressive language that was fluent and appropriate but not appropriately used, along with difficulty understanding and producing conversational discourse. In addition, concrete and literal conversation was appropriate but nonliteral conversation such as jokes and sarcasm could not be managed, and generalization could not be carried out from specific conversations. The difficulty in perceiving the central meaning of events and statements led to a strong preference for repetition and invariance, along with difficulty in new or overstimulating situations.
Diagnostic Criteria
The new DSM-5 category requires persistent difficulties in verbal and nonverbal communication in social settings, manifested by all of the following. There are deficits in social communication, such as greeting or sharing information in an appropriate manner. There is difficulty with changing communication to match the listener (e.g., an adult versus a child) or the context (e.g., classroom versus playground). Stereotypic or formal language may be inappropriately used for informal conversation. There is difficulty with the rules governing conversation, such as speaking in turn, repeating information if not clearly understood, and regulating conversation in response to verbal and nonverbal information from others. Inference of what is not explicitly stated may not be made, or language with ambiguous meaning may not be correctly interpreted, such as metaphors or jests. These problems must cause functional limitations in effective communication, social participation, relationships and academic or occupational performance, either individually or in combination. The symptoms must begin in the early developmental period, when language is usually acquired, and must not be better accounted for by another mental disorder or a general medical or neurological condition. In particular, cognitive impairment causing low abilities in the domains of word structure and grammar cannot be the cause, and developmental delay, intellectual disability and autism spectrum disorder must be excluded.
Incidence and Prevalence of SCD
Because SCD is a newly-defined disorder, its incidence and prevalence cannot yet be determined. It is likely to be substantial, particularly among children in school, because communication disorders are estimated to be among the most common disabilities in the United States. Approximately 6.1 million children in public schools received services under the Individuals with Disabilities Education Act (IDEA) in 2003, of whom 24.1 per cent (about 1.5 million) had speech or language disorders (US Department of Education, 2005). Estmates of language disabilities in preschool children range from 2 to 19 per cent5. Similarly wide-ranging estimates of the prevalence of autistic spectrum disorder have been published (less than 1 to 1,300 per 10,000 individuals) (Charman, 2002), and many SCD sufferers have been incorrectly diagnosed with this or with the miscellaneous subcategory of pervasive developmental disorder (18-60 per 10,000 prevalence) (Mugno et al., 2007). The diagnosis of Asperger’s syndrome, in which disturbed social communication predominates but is accompanied by restricted and repetitive behavior and interests, has been withdrawn from the DSM-5, which attempts to replace imprecise and eponymic diagnoses, but the syndrome’s prevalence has been estimated at 2 to 97 cases per 10,000 (Fombonne, 2003). No patients will “lose” the diagnoses of Asperger’s syndrome, Pervasive Developmental Disorder-NOS or Autism that they may have received in the past, but it is likely that the above population will contribute subsequent cases of SCD.
Clinical Features and Causes
Possible premonitory signs of semantic and pragmatic language disturbance were described in the initial report of Rapin and Allen (Rapin & Allen, 1983). Their patients had been quiet and usually content babies but difficult toddlers with no sense of danger, liked to play alone and repetitively, had not responded when called and were sometimes thought to be deaf, and did not babble and talked late but then often spoke out of context and in stereotypic phrases (often memorized from television). They often pointed late and had difficulty expressing wants and needs, but were fussy eaters and excessively sensitive to texture and sometimes to sound or touch. They were late in recognizing themselves in mirrors and pictures and had inconsistent eye contact, and later became “loners” who preferred to play alone and were poor at initiating play, although often able to join in general rough-and-tumble. They were poor at sharing as well, and often had tantrums, and often preferred helping with real household activities to playing. In later years they were generally independent and did not ask for help, repeated what was said to them and had obsessive interests and difficulty following rules, but were very good at puzzles, letters and numbers, shapes and colors. They came to speak clearly and in long sentences, acquired vocabulary well in areas of interest, and were often highly proficient in music, mathematics and with computers.
A disturbance of sensory integration has also been noted. Some children with the disorder have had heightened sensitivity to sound, while others have ignored loud noises and focused on sounds in the background. Heightened awareness of smell or taste can lead to food dislikes, while other patients have had diminished awareness of hunger and failure to eat unless prompted. Many children are reported to avoid touching certain types of surfaces, particularly wet and sticky ones, and awareness of pain is often diminished after an initial injury but may be enhanced after injury is appreciated or blood is seen (Rapin & Allen, 1983).
A specific cause for these symptoms has not been demonstrated, but either a genetic predisposition and environmental influences or a disturbance of development around the time of language acquisition have been suggested. Between 30 and 60 per cent of children with speech or language disabilities have a parent or sibling who is similarly affected (US Department of Education, 2005). Choudhry and Benasich estimated in 2003 that the incidence of specific language impairment in families with a history of such disorders was 20 to 40 per cent (Choudhury & Benasich, 2003). Among families with a child having a disorder in the autistic spectrum, the chance of having another affected child is 2 to 8 per cent, which is greater than for the general population (Muhle, Trentacoste & Rapin, 2004).
Treatment of Social (Pragmatic) Communication Disorder
Medical treatment of developmental disorders has been essentially ineffective, although psychostimulants have been used for impulsivity and hyperactivity and atypical antipsychotic drugs have been suggested to lessen some of the behavioral disturbances of autism (Strock, 2004). There have been no studies of drug treatment for the communication disorders.
Speech and language professionals recommend the early assessment of cognition, language, hearing and speech in children with social interaction problems. Guidelines have been published for individuals with autism and pervasive developmental developmental disorder which are applicable to SCD (Gerber et al., 2012). There is general agreement that the educational and occupational prognosis is poor for patients who receive no intervention, and some evidence can be found for almost all of the educational and behavior modification methods that have been proposed, but high-level evidence from controlled clinical trials is not available. Since SCD patients will by definition not have the intellectual limitations and behavioral problems that have hampered treatment of autism and related disorders, it is reasonable to anticipate therapeutic benefit.
Treatment modalities that have been used include augmentative and alternative communication (AAC), computer-based instruction and video-based instruction. AAC involves supplementation of speech communication with symbols or tangible objects, which may require a transmission device, or with unaided gestures and manual signing that may enhance communication. Computer-based instruction uses programs designed to teach social skills and understanding, while video-based instruction, also called video-modelling, uses videotaped interactions to practice communication skills.
Behavioral interventions supported by some evidence include applied behavioral analysis (ABA), functional communication training (FCT), incidental teaching, milieu therapy, pivotal response training (PRT), ABA is based on behavioral theory and utilizes observation of social interactions to make modifications in the environment to facilitate social communication. FCT involves the assessment of the communicative function of maladaptive behavior in order to teach alternative responses that communicate more effectively. Incidental teaching and milieu therapy are carried out throughout the day and not just in “therapy” periods: the former offers reinforcement of more effective communication and adaptive behaviors as these occur throughout the day, while the latter attempts to integrate communication training into other activities during the day. PRT attempts to teach “pivotal” skills that are needed for effective social interactions, such as the ability to respond appropriately to multiple cues, initiate social contact and self-regulate impulses. PBS replaces or supplements negative reinforcement of maladaptive behavior or ineffective communication with positive reinforcement of appropriate words and actions when they occur. The general concensus is that “there is much support for the use of interventions based on ABA, and these techniques should continue to be used in practice” (Reichow & Volkmar, 2010).
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, ed. 5. Washington, DC: APA Press.
Bishop, D.V., Norbury, C.F. (2002). Exploring the borderlands of autistic disorder and specific language impairment: a study using standardized diagnostic instruments. J Child Psychol Psychiat and Allied Disc, 43(7): 917-929.
Charman, T. (2002). The prevalence of autistic spectrum disorders: Recent evidence and future challenges. Eur Child Adolescent Psychiat, 11(6), 249-256.
Choudhury, N., Benasich, A.A. (2003). A family aggregation study: the influence of family history and other risk factors on language development. J Speech Lang Hearing Res, 46(2): 261-272.
Fombonne, E. (2003). Epidemiologic surveys of autism and other pervasive developmental disorders: An update. J Autism Devel Disord, 33(4), 365-382.
Gerber, S., Brice, A., et al. (2012). Language use in social interactions of school-age children with language impairments: An evidence-based systematic review of treatment. Lang Speech Hearing Services in Schools, 43(2): 235-249.
Mugno, D. et al. (2007). Impairment of quality of life in parents of children and adolescents with pervasive developmental disorder. Health Qual Life Outcomes, 5: 22.
Muhle, R., Trentacoste, S.V., Rapin, I. (2004). The genetics of autism. Pediatrics, 113(5): e472-486.
Nelson, H.D., et al. (2006). Screening for speech and language delay in preschool children: Systematic evidence review for the U.S. Preventive Services Task Force. Pediatrics, 117(2), e298-e319.
Rapin, I., Allen, D. (1983). Developmental language disorders: Nosologic considerations. In, Kirk U (ed). Neuropsychology of Language, Reading and Spelling. San Diego: Academic Press, 155-184.
Reichow, B., Volkmar, F.R. (2010). Social skills intervention for individuals with autism: Evaluation for evidence-based practices within a Best Evidence Synthesis framework. J Autism Devel Disord, 40, 149-166.
Strock, M. (2004). Spectrum Disorders (Pervasive Developmental Disorders). NIH Publication no. NIH-04-5511. Bethesda MD, National Institutes of Health, U.S. Department of Health and Human Services.
U.S. Department of Education. (2005). To Assure the Free Appropriate Public Education of all Americans: Twenty-seventh annual report to Congress on the implementation of the Individuals with Disabilities Education Act. Retrieved from: http://www.ed.gov/about/reports/annual/osep/2005/index.html.
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