When you’re engaged in conversation, do you actively think of what to say? Do you hope to the heavens that you won’t mess up? Are you aware of your body language? Or does the conversation flow naturally without you needing to think about it? For many of us, we experience the latter, but for people with social pragmatic disorder or ASD, all of the above challenges can be true.
Unfortunately, some individuals with different abilities can experience deficits in communication and struggle with even uttering a word or to understand any implicit word, phrase or tone the other person in the conversation says.
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There are several different types of communication disorders and each with their own criteria. In this article, we will look at what social pragmatic disorder (SCD) is and how it differs from autism spectrum disorders (ASD). The link between the two is centered on their similarities in communication deficits; so are they one and the same? Let’s discuss.
What does social pragmatics mean?
Social pragmatic language impairment refers to the ability of children to use language and interact with others within a social setting or group. Basically, it is the way we share and the manner in which we do, how our body language resonates with what is being said, and the ability to take turns throughout the conversation and respond appropriately; such as the ability to make eye contact with the speaker, and knowing when to listen and not talk.
It is important to note that communication is not limited to verbal speech; our ability to convey emotions, to engage with others and be present so that our thoughts and feelings are conveyed to those around us, all form part of communication. Hence why social communication is enabled by social competence (in other words, how well an individual is able to form relationships with others).
To be socially competent means to have the ability to internalize and assess a situation, perceive the behavior and social cues presented and thereafter adapt, initiate or respond accordingly. This includes our body language and the gestures we make. Therefore, it is important to assess whether a child is able to recognize both verbal and non-verbal cues to ascertain his/her level of communication skill.
So what is social pragmatic communication disorder (SCD)?
In 2013, the DSM-5 introduced a new diagnostic category under the Communication Disorders in the Neurodevelopmental Disorders section called social (pragmatic) communication disorder (SCD).
Just as the name suggests, SCD impacts the social aspect of communication. Individuals with SCD are considered literal in thinking and find it difficult to understand non-verbal cues and non-literal language such as sarcasm, metaphoric humor or humor in general, idioms, and metaphors. They also find it difficult to engage in conversation with ease, i.e. take turns during conversation, using gestures, social greetings and mannerisms, as well as integrating language with non-verbal behaviors.
As it stands, in order for social pragmatic communication disorder to be diagnosed, a child needs to have developed sufficient language skills; typically this means diagnosis can not be made until the age of four to five years.
Social communication disorder can occur in conjunction with other communication disorders such as language disorder, speech sound disorder, childhood-onset fluency disorder, and unspecified communication disorder (as per the DSM-5). However, social communication disorder cannot be diagnosed if a child has autism.
Is social pragmatic communication disorder on the autism spectrum?
Similarities between autism spectrum disorder (ASD) and SCD have raised questions on whether a diagnosis of SCD rules out autism. To answer this question, let’s differentiate between the two disorders.
Differences between ASD and SCD
|Traits||Autism spectrum disorder||Social pragmatic communication disorder|
and interaction skills
|Because autism is a spectrum, each child with an autism diagnosis experiences different levels of challenges in communication and interaction. Typical challenges a child might have include:|
• Avoids or does not keep eye contact
• Difficulties with expressing or recognizing facial expressions
• Struggles with turn taking
• Uses few or no gestures
• Delayed language skills
• Difficulty in understanding what is socially-acceptable
|• Difficulty responding to others in conversation|
• Difficulty adapting and changing communication to match the behavior of the listener
• Difficulty understanding implicit and non-verbal communication
• Difficulty in acquiring and using spoken and written language
|Interests||• Plays with toys in the same way every time|
• Repeats words and phrases (echolalia)
• Repetitive body gestures and movements i.e., hand flapping, rocking body
|Restricted or repetitive interests aren’t linked to SCD|
|Cognitive ability||Some children can have difficulty regulating and controlling their behavior and can also have an enhanced ability to perceive details. The cognitive strengths and weaknesses of a child with ASD differ across the spectrum.||Difficulty in understanding verbal and non-verbal communication is not linked to low cognitive ability|
In both cases, individuals diagnosed with autism or SCD experience difficulty with verbal and non-verbal communication.
Essentially, because both autism and social pragmatic communication disorder have similarities in terms of communication ability, in order to diagnose a child with SCD, a diagnosis of ASD needs to be ruled out. Based on the criteria of the DSM-5, to diagnose a child with ASD, the child needs to have traits of repetitive patterns of behavior, special interests or activities in addition to communication issues. I cannot emphasize enough that it is wrong to assume SCD is a “milder form” of ASD. Yes, there are similarities, just like any other communication disorder included in the DSM-5, but these two conditions are significantly different from each other in their criteria.
Treatment for social pragmatic communication disorder
As with all treatment strategies, it is important to make any form of intervention child-focused. Doing this allows the therapist, facilitator or parent to understand the weaknesses of the child so that the child improves on those areas specifically. When it comes to SCD, treatment should be within the frame of social interactions and work to eliminate factors that form barriers in order to facilitate communication and participation.
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There are several forms of treatment that can help improve a child’s social communication skills. Some treatment modalities include augmentative and alternative communication (AAC) and video modeling. Typically, speech therapy is most common for social communication disorder, but another form of therapy parents can consider is drama therapy. Let’s take a look.
Types of therapies
Speech and language therapy
Speech and language therapy is performed by qualified speech-language pathologists (SLPs). The goal of speech and language therapy is to improve a child’s communication through techniques such as speech articulation, language intervention activities, and helping with other areas of difficulty that the child experiences.
During the session, the child engages in activities such as talking and playing, using books, pictures, other objects, and modelling sounds and syllables. A child with SCD can benefit from this form of therapy because he/she is able to work on conversation skills. Role playing can also be part of the activities and it can cover areas such as interaction and turn taking, ultimately working on communications and social skills.
Drama therapy was founded by Jacob Levy Moreno and is a relatively unknown form of therapy for many. Through the use of drama and/or theatre techniques, the aim is to achieve a therapeutic goal with tools from psychotherapy. The beauty of drama therapy is it allows a client to use written, non-verbal, and verbal means of expression derived from theatre practices for the purpose of psychotherapy.
The goals of a session are specific to the needs of the client. Therapy can take the form of storytelling, social stories, embodiment, play, enactment, role play, and puppetry, to name a few. By creating a safe space, the child is able to explore an aspect of themselves that is challenging to them abstractly or metaphorically. With the guidance of the therapist, the child can interact with narratives from the stories created in order to dive into the internal world of the child.
When it comes to social skills and communication, drama therapy uses subtle tones or words that others communicate with so that it’s easier for the child to understand. Social skills can be built through teamwork or team building scenarios that are not directed at the child but allow him/her to step into that space.
Augmentative and Alternative Communication (AAC)
AAC is an alternative form of communication device that replaces natural speech with aided symbols such as picture communication, line drawings, and tangible objects; or unaided symbols such as natural signs, gestures, and finger spelling. AAC could be effective for children with social pragmatic communication disorder because it gives them a different form of expressing themselves and they are able to model what they’re trying to communicate.
Video modelling is an evidence-based practice whereby a child is recorded doing a task up until the desired response is achieved. When this is done, the video is edited to only include parts of the interaction from the beginning to the end where the child responds accurately, omitting any prompts or cuing from the parent, therapist or facilitator.
The video is then shown to the child and ideally encourages the child to perform the task without assistance. Any inappropriate behavior is edited out so that the child only sees themselves doing the task entirely on their own/independently.
This method can be effective for children with SCD because it helps them see themselves capable of achieving the task and the more times they do, the more the behavior becomes natural.
Other methods of intervention
Using social stories allows the child to see him/herself through the characters in the story. The story could explain social situations to the child and help him/her learn socially acceptable behaviors and responses.
Comic strip conversations
How fun would it be to create comic strips with your child? Filled with stories he/she will enjoy and can easily relate to.
Comic strip conversations allow you to create dialogues between two or more people depicting real life scenarios. Through these conversations, the drawings can illustrate what the characters are saying, doing, and thinking. Ultimately, comic strips can be effective in building problem solving skills, communicating feelings and perspectives, and conflict resolution.
From our knowledge of the DSM-5, we understand that SCD and ASD are characteristically different based on their respective criteria. Although there exists some overlap, clinicians and parents need to consider all the criteria for each disorder in order to deliver an accurate diagnosis.
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Remember a diagnosis of social pragmatic communication disorder should not be considered a “milder” form of ASD; each diagnosis is different.Thanks to improvements in medicine and therapy options, there are so many interventions that parents can take advantage of to help their child with either condition. Take time, do your research, and you can help your child achieve great things.
Brukner-Wertman, Y., Laor, N., & Golan, O. (2016). Social (Pragmatic) Communication Disorder and Its Relation to the Autism Spectrum: Dilemmas Arising From the DSM-5 Classification. Journal of autism and developmental disorders, 46(8), 2821–2829. https://doi.org/10.1007/s10803-016-2814-5
Mandy, W., Wang, A., Lee, I. and Skuse, D. (2017), Evaluating social (pragmatic) communication disorder. Journal of Child Psychology and Psychiatry, 58: 1166-1175. https://doi.org/10.1111/jcpp.12785
Social Communication Disorder, https://www.asha.org/practice-portal/clinical-topics/social-communication-disorder/#collapse_6
Swineford, L.B., Thurm, A., Baird, G. et al. (2014) Social (pragmatic) communication disorder: a research review of this new DSM-5 diagnostic category. Journal of Neurodevelopmental Disorders, 6, 41 . https://doi.org/10.1186/1866-1955-6-41