From the Desk of Ann Kummer
Language is a construct with the singular purpose of providing a means for human communication. Most humans develop language skills quickly and easily so that they can effectively communicate with others, even as young children. However, human language is complex and has many components. As such, it is not surprising that some children are able to develop some components of language normally (such as semantics, syntax, and morphology), while lacking normal development of another component (such as pragmatics).
For many years, the term “pragmatics” has been used to refer to the social use of language and the term “pragmatics disorder” has been used to describe difficulty with social communication skills. More recently, the term “social communication disorder” (SCD) has been adapted to describe a deficit in the social communication skills. In fact, SCD has been added as a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
SCD is a complex disorder that can have a devasting effect on the ability to function well in society. Because it is so important to recognize this disorder and intervene promptly after diagnosis, I am particularly excited about this article! This article was submitted Dr. Donna Murray, who is a well-known and greatly respected expert on this topic.
Donna Murray, PhD, CCC-SLP, is the Vice President of Clinical Programs at Autism Speaks and Adjunct Professor of Clinical Pediatrics at Cincinnati Children’s Hospital/University of Cincinnati College of Medicine. An autism clinician and researcher, Dr. Murray joined Autism Speaks in 2013 and oversees the activities of the Autism Care Network, an autism learning health system, specializing in the development and dissemination of evidence-based protocols and standards of care to improve outcomes for all children with autism. Prior to joining Autism Speaks, Dr. Murray served as Director of Clinical Services for the Division of Developmental and Behavioral Pediatrics, at Cincinnati Children’s Hospital, and the Co-Director of its Kelly O’Leary Center for Autism Spectrum Disorders. Dr. Murray has spent more than 30 years as a clinician specializing in program development, diagnosis, and treatment of individuals with autism. Her research includes studies examining language, social skills, diagnosis, and the impact of co-occurring conditions in autism. She has numerous publications on the diagnosis and treatment of autism and its related physical and mental health conditions. Dr. Murray’s current focus includes using quality-improvement science and research to improve clinical care and outcomes for children with autism and emphasizes the dissemination and implementation of evidence-based, best-practice findings.
This course will provide you with a great overview of SCD! You will learn about the common characteristics of SCD, methods for evaluation, and evidence-based interventions.
Now…read on, learn, and enjoy!
Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q
20Q: Social Communication Disorder
After this course, readers will be able to:
- Identify social communication disorder (SCD) and its common representing symptoms.
- Describe methods for evaluating SCD.
- Describe the differential diagnosis of SCD from autism spectrum disorder (ASD).
- List at least 2 evidence-based interventions to address SCD.
1. What is Social (Pragmatic) Communication Disorder?
Social Communication is the ability to appropriately use language in social contexts and includes social interaction, social cognition, pragmatics, and language processing. Social (Pragmatic) Communication Disorder (SCD) is characterized by difficulties with social interaction, social understanding, and appropriate use of language proper contexts (American Speech-Language-Hearing Association [ASHA] Practice Portal). This description is consistent with the diagnostic criteria set forth by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (5th ed.; DSM–5; American Psychiatric Association [APA], 2013) for Social (Pragmatic) Communication Disorder. The DSM-5 criteria for SCD includes persistent difficulties in the social use of verbal and nonverbal communication and indicate that the deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance. Swineford, Thum, Bair, Wetherby, and Swedo (2014) indicate that sufficient language skills must be developed before higher-order pragmatic deficits can be detected, therefore a diagnosis of SCD should not be made under the age of 4. It should be noted that SCD may co-occur with other conditions such as intellectual disability, developmental disabilities, language and learning disorders, and ADHD. However, to make a diagnosis of SCD the individual cannot meet criteria for an autism spectrum disorder (DSM-5, 2013).
2. Why was SCD added to the DSM-5 in 2013, this isn’t really a new diagnosis is it?
The addition of SCD to the Neurodevelopmental Disorders section of the DSM-5 in 2013, led many to believe that this is a newly identified condition. However, SCD has been in SLP literature for many years as Pragmatic Language Impairment. SCD was added to the DSM-5 to provide healthcare providers new guidance in diagnosing mental and behavioral conditions (Paul & Murray, 2015). SCD provided a diagnostic category for those that may have met criteria for the broader Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) in DSM IV but would not meet criteria for ASD under DSM-5, providing a diagnostic category to access needed treatment services. The addition of SCD in the DSM-5 was also based on research that pragmatic impairments observed in SCD are different than difficulties observed in specific language impairment (Swineford, et al. 2014). However, the inclusion of SCD as a distinct diagnostic category does not have universal agreement. There remains debate on the utility of an independent SCD diagnosis (Norbury, 2014, Tager-Fluberg 2018, Taylor & Whitehouse, 2016,). Swineford et al. (2014) suggests that the addition of SCD to the DSM-5 doesn’t settle the debate rather provides a tool to assist in the development of empirical evidence to answer the question.
3. When should we screen or assess for SCD?
SCD should be suspected if there are observed difficulties with both verbal and non-verbal social communication skills. Additionally, SCD should be screened in every comprehensive communication evaluation, when there are educational or job performance concerns, difficultly making and keeping friends, behavioral concerns, or other co-occurring condition such as ADHD or learning disorder.
Consider possible SCD (or differential diagnosis of ASD) if the following difficulties are indicated on observation or in caregiver/teacher report.
- Early skills
- Using or understanding gestures (waving, pointing)
- Using or understanding facial expressions
- Responding to others
- Taking turns
- In verbal or older students and adults
- Staying on topic
- Conversational turn-taking
- Expressing emotions or feeling
- Adjusting speech to fit the situation (peer vs. authority figure, calls vs. playground)
- Providing background information to unfamiliar conversational partners
- Understanding jokes or making inferences
4. I know SCD can’t be diagnosed with ASD, but what about other conditions?
True, many with SCD may have previously been diagnosed with mild autism or Pervasive Developmental disorder, not otherwise specified (PDD-NOS). Differential diagnoses can be difficult because many symptoms and behaviors of SCD overlap with ASD. As we have discussed, SCD cannot be diagnosed in individuals that meet criteria for ASD, but SCD commonly coexists with other developmental disorders such as specific learning disorder, ADHD, intellectual developmental disorder, and language delay or it may occur with traumatic brain injury, or degenerative disorders such as dementia. Therefore, including a speech-language-pathologist trained to identify and differentially diagnose social communication difficulties is important.
5. How is a differential diagnosis of SCD or ASD made? There appears to be a lot of overlap.
Indeed, there is a lot of overlap. Matter of fact, social communication difficulties are a defining feature of autism spectrum disorder (ASD) along with restricted and repetitive behaviors. It is this restrictive and repetitive behavior that is the defining difference between SCD or ASD. However, this isn’t always straightforward, and more research is needed to better understand the overlaps, differences, or continuum, between these conditions.
6. Who can diagnose SCD and what is the role of the SLP in treatment?
The American Speech-Language-Hearing Association (ASHA) indicates that Speech-Language Pathologists are qualified to independently diagnose SCD. Information from the ASHA practice portal on Social Communication Disorders states “Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of social communication disorder in children and adults. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment), advocacy, education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology” (ASHA, 2016b) for more details. However, it is always wise to check with your state board for questions regarding state regulations. And it is helpful to refer to the ASHA practice portal for detailed information on the roles and responsibilities of the SLP in the diagnoses and treatment of SCD.
7. What should be included in a comprehensive assessment of social communication?
As mentioned previously, SCD often coexists with other developmental, learning, and language concerns so it is important that SCD is evaluated and considered within a comprehensive speech and language assessment. An evaluation of social communication should include input from caregivers and teachers and optimally include observation in a variety of social contexts including structured and unstructured interaction with peers. If there is limited access to peers, the SLP may decide to set up a small group social situation with peers and design some activities that may elicit the desired social behaviors. However, this is not always possible, especially in outpatient clinical settings. In these cases, the SLP will have to rely on detailed input from caregivers and teachers. A diagnosis of SCD should not be made without observations and/or input from others with knowledge of the student’s interaction and social competence in a variety of settings. There are several informal checklists and rubrics available to assist the SLP in documenting observation of social communication across contexts. Although these are not standardized, they are useful for describing strengths and challenges in more detail and across contexts, and in developing treatment plans.
8. Are there structured or standardized assessments to assist in the diagnosis of SCD?
There are some standardized assessments that assess various aspects of SCD as well as subtests and checklists. These can be helpful tools in making a diagnosis of SCD. However, it is imperative that behaviors be considered across settings and considering communication stressors such as interactions with peers versus adults, sensory stressors, new situations, non-structured or unpredictable environments. Observational assessment and caregiver and teacher input are imperative in both making a diagnosis of SCD and determining therapeutic targets. There is a risk of cognitive override on standardized assessments since most assessments take place in a quiet 1:1 environment. It is usually not possible to evaluate interactions in groups or with peers so observation in these various settings is optimal. If direct observation is not possible, then it is critical to obtain input from caregivers and teachers.
Below are some standardized assessments that may be helpful, in combination with observation and checklists, in evaluating social communication (pragmatic) skills. This is not exhaustive nor is it an endorsement of specific assessments, but I want to provide a broad overview for consideration.
- Children’s Communication Checklist, Second Edition (CCC-2), Bishop 2006
The CCC-2 is a standardized assessment designed to assess the communication skills of children between the ages of 4.0 to 16.11 years. The purpose of the CCC-2 is the identification of pragmatic impairment, screening of receptive and expressive language and it is useful to identify children that require additional assessment for ASD.
- Test of Pragmatic Language -2 (TOPL-2), Phelps-Teraskaki (2007)
The TOPL -2 is a standardized assessment designed to evaluate the effectiveness and appropriateness of a student’s pragmatic language in children 6 to 18 years of age. It assesses six core components of pragmatic language: physical setting, audience, topic, purpose, visual-gestural cues, and abstraction.
- Language Use Inventory (LUI), Neil 2009
The LUI is a standardized parent questionnaire to assess pragmatic language in toddlers 18 -47 months of age. the LUI is designed to identify children with delays or impairments in pragmatic language development and identify children who require further evaluation of expressive language skills.
- Clinical Assessment of Pragmatics (CAPs), Lavi (2019)
The CAPS is a standardized assessment of pragmatics for children between the ages of 7 to 18 years. This assessment reportedly addresses some of the weaknesses of other standardized assessment in that uses video of teenagers from diverse backgrounds engaging in social situations. These videos are used to assess pragmatic judgment and pragmatic performance.
- Test of Problem Solving -2 Adolescent (TOPS-2), Bowers et al (2007)
The TOPS 2 Adolescent assesses language-based, critical thinking abilities. It focuses on cognitive processes such as self-regulation, inference, analysis, evaluation, insight, problem solving, interpretation, explanation, and decision making.
- Social Language Development Test- Adolescent (SLDT-A), Bowers et a (2017)
The SLDT-A is a standardized assessment that measures language-based skills of social interpretation and interaction for students between 12 and 18 years of age. the assessment measures perspective-taking, inferencing, problem-solving with peers, interpretation of social language and understanding idioms, irony, and sarcasm.
- Targeted Observation of Pragmatics in Children’s Conversations (TOPICC), Adams et al (2011, 2012)
The TOPICC is a semi-structured task that allows for the rating of overall quality of interaction in conversation for students between the ages of 6-11year. The assessment evaluates conversational skills such as reciprocity, turn-taking, verbosity, topic management, discourse style. It should be noted that Nobury et.al determined that the TOPICC is a quick index of conversational skill, but currently lacks adequate interrater and test-retest reliability (Norbury (2014)
- Screening for SCD
Several language assessments have subtests or checklists that may assist in the diagnosis of SCD such as The Clinical Evaluation of Language Fundamentals-Preschool 2 (CELF P-2), Wiig et al (2013), and Comprehensive Assessment of Spoken Language-2 (CASL-2), Carrow-Woolfolk (2017). These are helpful in screening for concerns but are not comprehensive and should not be the sole indicator of an SCD.
9. Is speech-language pathology the only discipline that treats SCDs?
No, nor should they be. Social competence is context-dependent. For example, someone may demonstrate better skills in a one-on-one environment with a familiar adult but have challenges in a classroom or an unstructured environment such as the playground. It is important for there to be a support system across environments. The more you can build a team to provide opportunities to support learned skills in a variety of contexts, the better. The SLP plays an important role in not only providing direct intervention but also in providing support to this larger support system. This may include providing examples of how to structure opportunities to practice learned skills across environments, provide support materials such a visual support, and teaching others to implement social stories or how to support the student in various settings.
10. How can someone with an isolated Social Communication (Pragmatic) Disorder qualify for services in a school?
Many providers are concerned that students with isolated SCD won’t qualify for services in the school, but this is not necessarily the case. When considering eligibility for services in the schools there is a three-prong decision-making process (Speechpathology.com, 2018).
Prong 1- Is there a disability?
Is the student eligible for speech-language impairment under the Individuals with Disability Act (IDEA)? The inclusion of SCD as a diagnostic category in the DSM-5 is helpful. To make this determination a comprehensive assessment should be conducted. This assessment should include information describing the students’ academic and functional performance in relationship to age and developmental abilities. It should be noted that there is some variation from state to state on eligibility requirements
Prong 2- Is there an adverse effect on educational performance resulting from the disability?
The impairment must have an adverse impact on educational/school performance. It is very important to describe this as part of the assessment process. Educational performance does not have to be limited to academic performance. Of course, academic performance should be described and considered, but functional abilities within the class and school setting is also very important.
Prong 3- Are specially designed instruction and/or services needed to help the student make progress in the general education curriculum?
What service and supports are needed? Is this available, who will provide the service and in which environment, and what will be the amount is recommended?
11. What kind of educational impact does SCD have? What should I look for or be concerned about?
We most often consider the social impact of SCD, but perhaps less often think specifically about the impact on educational performance. Yet, SCD can have a significant impact on education. Neal (2018) described the impact on academics such as reading comprehension which requires skills in taking points of view, inferencing, understanding idioms, and having central coherence. Writing skills are often impacted due to difficulties in skills such as expressing thoughts, summarizing, and maintaining topics. When considering educational impact, it is important to consider functional abilities that lead to success in the classroom and school environment. Skills such as participating in the classroom, working in groups, interacting appropriately with peers, asking for help, or asking questions are critical to educational success. When conducting a comprehensive evaluation, it is imperative that the SLP describe educational performance in the evaluation report.
12. Social skills can be complex to write about in a way that effectively documents progress toward the goal, do you have any suggestions?
Because the complexity of social interactions becomes more sophisticated as a person matures, social competence becomes more complex. Mastering social skills requires multiple levels of mastery to become socially competent. When writing a goal for SCD it is helpful to break the skill down into three aspects. 1. The specific skill to be taught, 2. The setting of the skill (at home, at school with the therapist, in the classroom, in the community, structured environment, or unstructured such as a playground), 3. The social level of the skill (1:1, small group, larger group). This allows progress can be monitored and documented in several ways. One might be to increase the frequency in which the skill is initiated appropriately (skill specific). Another is to document the increasing levels and types of settings, and lastly, the social level in which the skill is mastered. By breaking down a skill you can create levels of mastery that demonstrate progress before a goal is mastered across settings and social contexts.
13. What type of setting is best for treating SCDs?
A blend of therapy environments may be used. It is often helpful to teach new skills in a 1:1 setting. Whereas a mix of 1:1 and small group settings are beneficial for targeted practice of those skills with peers, which is important for generalization. Once the skill is mastered in a small group setting, then moving to the broader school setting or community is important to fully generalize and establish skills (Timler, 2008)
14. Would an adult, in the absence of another co-occurring condition, benefit from the identification and treatment of SCD?
Absolutely! Teens and adults may feel isolated, unsuccessful in social interactions, and experience significant challenges in educational and work environments. They may be at a loss in understanding why they struggle which may lead to depression, anxiety, and behavior concerns.
Social competence is central in acquiring and maintaining employment. It is well established that the ability to acquire and maintain a job depends on much more than the knowledge or skills required to do the job and that people who demonstrate challenges in social skills report unemployment or underemployment. In fact, “Indeed” job site, listed the Top 11 skills valued by employers (2020). Of these skills, many require social communication competence:
- Interpersonal skills
- Computer skills
- Problem-solving skills
- Strong work ethic
So, it’s not surprising that, for those with SCD, difficulties in the workplace are often the result of social challenges/misunderstandings rather than a lack of skills required to do the job. Agran, Hughes, Thoma, & and Scott (2014) surveyed 651 secondary teachers to rate the importance of social skills in employments settings and the extent to which there was instruction provided to teach identified skills. The survey indicated a mismatch existed between the social skills most frequently taught and those rated as most important for employment success. More research is needed to continue to develop an intervention that better matches the development of social competence areas that best leads to employment success.
15. Are there evidence-based interventions to treat SCD?
SLPs should implement known evidence-based practices (EBP) when planning intervention. It is important to communicate clearly why you are implementing a specific approach and the evidence behind the strategy. Watkins, Kuhn, Ledbetter-Cho, Gevarter, O’Reilly (2015) conducted a literature review and indicated the following as Evidence-Based Practices (EBP). They mapped the EBP to the age group (Toddler, Preschoolers, Elementary, Adolescents). Although this work is based on findings in those with ASD, they can be useful to those without. More research is needed to expand potential interventions for those with isolated SCD.
- For all ages:
Antecedent-based intervention, modeling, prompting, reinforcement, video modeling, and visual supports
- Toddlers (0-2 years):
Usually, young children with ASD and other DD that have co-occurring social communication deficits since SCD as a distinct diagnosis is not usually made until the child is 4-5 years; naturalistic interventions, parent-implemented interventions, and pivotal response training
- Preschoolers (3-5 years):
Behavioral, naturalistic, and peer-mediated interventions (frequently used in combination)
- Elementary School-age:
Behavioral, peer-mediated intervention and instruction, social narratives, visual support, video modeling
Behavioral, peer-mediated intervention and instruction, self-management, visual cue strategies
ASHA's practice portal also lists the following as treatments for SCD:
- Augmentative and Alternative Communication (AAC)
- Computer-Based Instruction
- Video-Based Instruction (also called “video modeling)
- Behavioral Interventions/Techniques
- Social Communication Treatments
- Comic Strip Conversations
- Score Skills
- Social Communication Intervention Project (SCIP)
- Social Scripts
- Social Skills Groups
- Social Stories
16. Will you explain in more detail what video modeling is and how you’d use this approach?
Video modeling is an evidence-based practice that uses a video model to address teaching a targeted skill or to model appropriate behavior. The “performer” in the video may be the individual who is targeted to learn the skill or appropriate behavior, or it may be an “actor” modeling what is to be taught. There are quite a few benefits of using the video modeling technique.
- Treatment integrity – video modeling can be done by support staff who may not be highly trained with a high level of fidelity to what you want to highlight or teach.
- Produced videos can be used with several students work on the same targets
- Videos can be produced in natural settings where it might be difficult to teach skills.
- Video modeling is a non-intrusive technique.
- Some situations do not allow for enough natural opportunities for the individual to learn the skill.
- Video modeling may reduce the risk of prompt dependence.
- Video modeling capitalizes on Gestalt processing.
To create a successful video for video modeling, first identify a specific behavior or target. Be sure to target only one behavior or target per video. (i.e. greeting peers). Develop a written activity plan which will highlight the targeted objective including a script. Pair video with visual supports (script, social story, pictures, etc.) to underscore the salient information presented in the video clip. Review visual supports prior to viewing the video. View the video daily (more frequently if the student enjoys watching it).
As the video is weaned, the visual supports can be transitioned to support a student through the skill in increasingly natural situations (rehearsal, or to view prior to situations where the sill may be likely to occur).
17. How do you know where to start and what to target?
There are hundreds of discrete social skills so it’s no wonder that it is often overwhelming to think about where to start when developing an intervention plan for SCD. Rather than considering discrete social skills independently, it is helpful to think in terms of social competence.
Whereas social skills refer to the discrete skills that are taught, social competence refers to an individual’s social effectiveness. Social competence requires more than social skills. “Social competence is a complex and interconnected set of skills that enables us- when developing an intervention plan - to consider areas of social competence needed for successful interactions in relation to age, developmental levels and need, then organize the social skills required to achieve social competence.
For example, to effectively socialize in a school setting and participate successfully in small groups, the following social skills might be prioritized (in relation to the student’s skill and developmental level)
- Finding commonalities with peers
- Entering/Maintaining/Exiting conversations
- Conversational turn-taking
- Negotiation and compromise
Teaching social competence is important, beyond a strategy to prioritize skills to be taught, this approach weighs the “value” of mastery of a skill set relative to how it will enhance social performance.
18. How do you address SCD in this time of remote learning?
Addressing SCD through remote learning takes additional consideration. The most obvious approach for 1:1 intervention, allowing for the teaching of new skills. However, as skills are being established in the 1:1 remote learning setting it is very important to engage the caregiver and family members to help in practicing those skills outside of the therapy setting. Video modeling could be an excellent approach in that it provides a very structured approach in teaching a skill that could be implemented outside the telehealth session. It is more important than ever to train and support caregivers in providing opportunities to practice skills, integrating siblings if possible, to create a small group setting to practice skills and provide opportunities to practice these learned skills in a variety of contexts within the home and community.
19. How do you consider cultural and linguistic norms when evaluating and planning intervention?
DuPraw and Axner (PBS n.d.), describe six fundamental patterns of cultural differences that often lead to misunderstanding.
- Different Communication Styles
- Different Attitudes Toward Conflict
- Different Approaches to Completing Tasks
- Different Decision-Making Styles
- Different Attitudes Toward Disclosure
- Different Approaching to Knowing
ASHA describes cultural competence as the ability to “understand and appropriately respond to the unique combination of cultural variables and the full range of dimensions of diversity that the professional and client/patient/family brings to the interaction.” Social norms are a fundamental part of culture and communication. These norms often vary across and within cultures. It is always important when evaluating communication, but especially important when evaluating social communication, to acquire knowledge of the student’s cultural norms to determine what is considered typical for that student and family to differentiate communication differences from a disorder. For more information see ASHA's Practice Portal page on Cultural Competence and Multicultural Practice Management page for “Cultural Competence Checklists” to assist in a self-assessment of cultural competence.
20. What kinds of supports might be helpful for those with SCD?
Visual supports can be very helpful in assisting those with SCD. The unstructured aspect of social interactions can lead to increased anxiety which can then lead to behavior challenges, impulsivity, or withdrawal. Providing visuals to prompt or predict what to do in social situations, what to expect, and how to respond can go far in not only teaching skills but in reducing social anxiety issues. Visual cues can be used to prompt the student through an interaction or promote classroom participation. Visual supports and cues can also be used to reduce inappropriate or interfering behaviors (speaking out in class, leaving the classroom). Sometimes small visual prompts on a student’s desk as a reminder to raise their hand or ask before getting out of their seat can lead to increased success. Additionally, the environment can be used to provide visual cues for students. For example, structuring the classroom to clearly indicate leisure area, quiet area for reading, and the classroom work area, assists in defining the activities and social expectation of the area. Autism Speaks has a useful Visual Support Tool Kit and Visual Support One Pager that can be downloaded from the Autism Speaks website, and shared with families and teachers (Autism Speaks).
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