Dr. Oswald's Corner
Comments on recent
autism-related research reports
What is Social (Pragmatic) Communication Disorder?
The publication of DSM-5 (American Psychiatric
Association, 2013) saw the introduction of a new
diagnostic label into the psychiatric ‘bible’,
“Social (Pragmatic) Communication Disorder”
(S[P]CD; see Table 1). As we warily approach this
new entity, we might first reasonably wonder
what was in the collective mind of the task force
when they settled on its name. It is not a name
that previously existed (in this form) in the
psychiatric literature, nor in the literature on
developmental language disorders. But there are
clear echoes of earlier designations and the task
force must surely have expected us to reflect on
those various syndromes in the literature to
which this curious designation alludes. Indeed,
there has been a veritable chain of syndromes or
conditions or deficits that share some portion of
the name.
The lineage of S(P)CD goes back, at least, to
Rapin and Allen (1983) who are generally
credited with first describing a syndrome which
they called “semantic pragmatic syndrome
without autism.” In the context of a paper that
surveyed the range of developmental language
disorders, they described children with the
syndrome as producing “syntactically wellformed, phonologically intact” utterances that
were “often not really communicative.” They
noted “a severe impairment in the ability to
encode meaning relevant to the conversational
Table 1. Diagnostic Criteria
Social (Pragmatic) Communication Disorder 315.39 (F80.89)
A. Persistent difficulties in the social use of verbal
and nonverbal communication as manifested by
all of the following:
1.
2.
3.
4.
Deficits in using communication for social
purposes, such as greeting and sharing
information, in a manner that is appropriate
for the social context.
Impairment of the ability to change
communication to match context or the
needs of the listener, such as speaking
differently in a classroom than on a
playground, talking differently to a child than
to an adult, and avoiding use of overly formal
language.
Difficulties following rules for conversation
and storytelling, such as taking turns in
conversation, rephrasing when
misunderstood, and knowing how to use
verbal and nonverbal signals to regulate
interaction.
Difficulties understanding what is not
explicitly stated (e.g., making inferences) and
nonliteral or ambiguous meanings of
language (e.g., idioms, humor, metaphors,
multiple meanings that depend on the
context for interpretation).
situation, and a striking inability to engage in communicative discourse” as well as impaired
comprehension of connected discourse and “seemingly irrelevant responses” to questions. In the 30
years since that time, other scholars have tried to elaborate, or improve upon, that initial description,
often also tinkering with the name of the condition under investigation. “Semantic pragmatic syndrome
without autism” and its descendants constitute at least a hypothetical family tree for Social (Pragmatic)
Communication Disorder.
Consider how the newly minted S(P)CD lines up with its various forebears. Table 2 seeks to align the
features of the original version of the Rapin and Allen (1983) syndrome with features that are associated
with similarly-named conditions over the intervening years, up to and including DSM-5. A word of
caution: in most cases the features listed in the table were not specified by the authors as diagnostic
criteria for the condition under investigation; in some cases, they were extracted from relatively
informal descriptions. Also, the table is not exhaustive; there are other informal descriptions of similar
difficulties, but these are among the most frequently cited. Finally, aligning the features across the
conditions was done by art, not by science; readers will likely take issue with some of the alignments.
The table represents a good faith (if possibly naïve) effort to track the evolution of this elusive
conceptual entity.
So what can we learn from this exercise? First, by considering the names employed, we see that there
has been an abandonment of the notion of semantic differences as a defining characteristic. The term
“semantic” refers to the meaning of words and phrases. Rapin and Allen’s citation of impaired “ability to
encode meaning relevant to the conversational situation” and “’canned’ sentences without real
semantic content” presumably provided the rationale for including “semantic” in the condition’s original
name. But these features disappear from the descriptions over time, even as “semantic” disappears
from the names.
There are other features in the original description that have fallen by the wayside, including the quartet
of “echolalia,” “pronoun confusion,” “impaired syntax,” and “disruption of prosody.” While Rapin and
Allen (1983) considered these as part of the original syndrome, they have not been taken up by more
recent scholars. Clinical experience suggests that these features are also frequently noted in the
language of people with ASD and, as such, fail to distinguish pragmatic language impairment without
autism. Further, some later descriptions have explicitly excluded these features; for example, Rapin
(1996) concluded that syntax was “unimpaired” in “semantic-pragmatic deficit disorder”.
The literature reveals an increasing emphasis, over time, on the importance of “pragmatic” language
differences which DSM-5 seems to wish to equate with the term “social communication” difficulty. (Is
that what those parentheses in the DSM-5 name mean?) A common feature that has persisted across
almost all descriptions and that may help to clarify “pragmatic,” as it has been used in these papers, is
some form of “difficulty with communicative discourse or conversation.” The DSM-5 definition (criterion
A.3) characterizes this feature as “difficulty following rules for conversation and storytelling.”
The “ability to change communication to match context” (DSM-5 criterion A.2) enters the literature with
Bishop (1998) but is more clearly emphasized in Volden et al. (2009).
Tracking backward from DSM-5 criterion A.4 (i.e., “difficulties understanding what is not explicitly
stated”) is more difficult. There is a possible connection to Rapin and Allen’s (1983) “inability to deal
with abstract concepts” but the match is not perfect. DSM seems to emphasize difficulty grasping
implied meaning, which is not exactly the same as “comprehension deficits” or trouble with abstract
Table 2.Tracking the elusive pragmatic language disorder: Diagnostic features over the years
Rapin & Allen (1983)
“semantic pragmatic syndrome
without autism”
utterances that were not really
communicative
severe impairment in the ability
to encode meaning relevant to
the conversational situation
inability to engage in
communicative discourse
Rapin (1996)
“semantic-pragmatic
deficit disorder”
speaking aloud to no one
in particular
seemingly irrelevant responses
to questions
answering beside the
point of a question
echolalia
pronoun confusion
impaired syntax
disruption of prosody
use ‘canned’ sentences without
real semantic content to
maintain an interpersonal
interaction
inability to deal with abstract
concepts
Bishop (1998)
"semanticpragmatic disorder”
Adams (2001)
“semantic–pragmatic
language disorder”
inability to employ
world knowledge to the
act of communication
deficient turn-taking
skills, responsiveness
and initiation of topics
inadequate conversational
skills; poor maintenance
of topic
lack of coherence
inability to structure a
sequence of ideas into
connected discourse
Volden et al. (2009)
“pragmatic language
impairment”
Reisinger et al. (2011)
“pragmatic
language impairment”
DSM-5 (2013)
“Social (Pragmatic)
Communication Disorder”
difficulties identifying the
topic initiated by a speaker
and making a relevant
comment
difficulty maintaining the
topic of conversation
have problems
understanding and
engaging in ‘small talk’
difficulties following rules
for conversation and
storytelling
tangential speech
stereotyped
conversation
comprehension deficits
for connected speech
difficulties understanding
what is not explicitly
stated
word finding deficits;
atypical word choices
frequent
verbosity
word-finding problems
difficulty knowing how much
information is relevant to
include in an utterance
mismatch between language
and the situation in which it
is used
failure to make use
of context
impairment of the ability
to change communication
to match context or the
needs of the listener
fewer requests for
clarification of
information
difficulties recognizing
social cues
conversational responses
that are socially
inappropriate
deficits in using
communication for social
purposes in a manner that
is appropriate for the
social context.
concepts. It is possible that difficulty with implied meaning has not been clearly included in previous
descriptions and should be recognized as a new feature in the DSM.
Finally, the DSM criterion A.1, “deficits in using communication for social purposes in a manner that is
appropriate for the social context,” presents something of a challenge. It seems to overlap with the A.2
criterion in its focus on appropriateness to context; but “using communication for social purposes” is not
just a matter of context. There is some apparent connection to “socially appropriate” conversational
responses (Reisinger et al., 2011), but again the match is not perfect. The exact intent of this DSM
criterion is simply not clear.
This brief review makes it clear that S(P)CD did not spring, like Athena, “fully armed, from the head of
Zeus” (or from the collective heads of the task force members). There is a history here which the
diagnostic criteria build on, though some may find the DSM definition less-than-faithful to that history.
Two important empirical questions raised by the DSM definition are: “Do these specific communication
differences cluster together in nature?” and “Does this combination exist in a ‘pure’ form, justifying a
distinct diagnostic category, or only as difficulties that are invariably a part of some other condition?”
Even a brief look at the literature makes it clear that those questions are yet unanswered, largely
because the specific features included in the DSM definition of S(P)CD have not yet been systematically
examined as a syndrome. While Gibson et al. (2013) sought to distinguish “pure” Pragmatic Language
Impairment (PLI) from ASD, the form of PLI that these scholars investigated did not exactly correspond
to S(P)CD, and further the results were somewhat equivocal. One might have hoped for a clearer answer
to those questions before the diagnosis was formalized in a manual that is intended to be a prominent
guide for clinical practice.
A more urgent practical question is: “How will the advent of this diagnostic label affect real people with
disabilities?” The task force appears to have been motivated in part by the need to acknowledge the
existence of individuals with social communication difficulties (as seen in ASD) who do not have the
restricted interests or repetitive behaviors associated with ASD. This seems a worthwhile goal, although
the size of that population is as yet unknown. However, if that was the goal, one wonders why the
defining characteristics of S(P)CD do not better align with the social communication criteria of ASD; even
a casual comparison reveals that the social communication differences identified in S(P)CD are
substantively different from the defining characteristics of ASD.
Further, the new diagnosis of S(P)CD is launched to a network of professionals who are singularly
unprepared to use it constructively. Aside from any vagueness built into the criteria, few developmental
specialists and even fewer mental health professionals are adequately prepared to competently assess
pragmatic language impairment.
If we are looking for a silver lining, one might say that the existence of this diagnosis offers yet another
testimony to the value of collaborative multidisciplinary assessment teams. Psychologists,
developmental pediatricians, and child psychiatrists who do not have access to the expertise of a
speech/language professional will be at a distinct disadvantage when it comes to making valid diagnoses
of S(P)CD.
References
Adams, C. (2001). Clinical diagnostic and intervention studies of children with semantic–pragmatic
language disorder. International Journal of Language & Communication Disorders, 36(3), 289-305.
doi:10.1080/13682820110055161
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, DC: Author.
Bishop, D.V.M. (1998). Development of the Children’s Communication Checklist (CCC): A method for
assessing qualitative aspects of communicative impairment in children. Journal of Child Psychology and
Psychiatry, 39, 879-891.
Rapin, I. (1996). Developmental language disorders: A clinical update. Journal of Child Psychology and
Psychiatry, 37, 643-655.
Rapin, I. & Allen, D. A. (1983). Developmental language disorders: nosologic considerations. In U. Kirk
(Ed.), Neuropsychology of language, reading, and spelling (pp. 155-184). New York: Academic Press.
Reisinger, L.M., Cornish, K.M., & Fombonne, E. (2011). Diagnostic differentiation of autism spectrum
disorders and pragmatic language impairment. Journal of Autism and Developmental Disorders,
41:1694–1704. doi 10.1007/s10803-011-1196-y
Volden, J., Coolican, J., Garon, N., White, J., & Bryson, S. (2009). Brief report: Pragmatic language in
autism spectrum disorder: Relationships to measures of ability and disability. Journal of Autism and
Developmental Disorders, 39(2), 388-393. doi:10.1007/s10803-008-0618-y
Donald Oswald, PhD
Director of Diagnostics and Research
Commonwealth Autism Service
[email protected]