Overview
Social (Pragmatic) Communication Disorder is a neurodevelopmental disorder characterized by the inadequate ability to engage in pragmatic communication, or conversation that makes use of social context.
Individuals with the disorder may show an inability to make inferences, as well as an inability to decipher idioms, metaphors, and humor. The symptoms of the disorder can have significant functional consequences, which may be amplified in interpersonal relationships.
The etiology of the disorder remains unclear. Genetic, environmental, and neuroanatomical factors are identified as potential correlates. Social (Pragmatic) Communication Disorder presents with symptoms which often overlap with those of other neurodevelopmental disorders, particularly Autism Spectrum Disorder, as well as other psychiatric disorders such as ADHD, bipolar disorders, and schizophrenia.
It is important to differentiate between these on the basis of certain distinguishing symptoms of underlying disorders that may not appear in the manifestation of Social (Pragmatic) Communication Disorder. In the case of distinguishing between Autism Spectrum Disorder, for instance, the absence of a history of restricted or repetitive behaviors may indicate the presence of Social (Pragmatic) Communication Disorder.
Currently, the only evidence-based treatment modality for the disorder is speech therapy.
Signs and Symptoms
The signs and symptoms of Social (Pragmatic) Communication Disorder may include:
- Difficulty in understanding the social rules of language
- Being unable to understand the nuances of language and only interpreting literal meanings
- Being unable to change pragmatic language according to context or pick up on contextual cues
- Delay in reaching language milestones
- Structural language problems
- Avoiding social interaction
Risk Factors
The prevalence of Social (Pragmatic) Communication Disorder is largely unknown due to a paucity in epidemiological surveys as well as the disputed nature of its validity. The onset of the disorder is considered to be in childhood, though cannot be picked up on before the age of 4-5 due to the importance of the language quotient.
In case of a failure to meet language milestones considered in development by the age of 4-5, the signs of the disorder may become apparent. However, in mild manifestations, the disorder may go unacknowledged until adolescence.
Etiological correlates of the disorder are unclear. The primary factor considered in the causation of Social (Pragmatic) Communication Disorder is genetics. Difficulties with respect to pragmatic language have been observed to run among families, and the same is considered to be true for Social (Pragmatic) Communication Disorder.
There is a considerable overlap in the genetic correlates of Autism Spectrum Disorder and Social (Pragmatic) Communication Disorder.
Studies have determined that an excess of the X and Y chromosomes may be related to structural and pragmatic impairments, while the supernumerary Y chromosome in particular was associated with problems of pragmatic language.
Due to evidence of developmental changes in the effect of genetics, the importance of environmental factors is also speculated.
Certain neuroanatomical abnormalities, particularly, deformations in the bilateral medial caudate and the integrity of the frontoparietal tracts was associated with problematic social communication. Problems within certain language networks in the brain may be relevant to the causation of the disorder.
Diagnosis
The diagnosis of Social (Pragmatic) Communication Disorder may prove to be challenging due to the significant overlap of symptoms with those of Autism Spectrum Disorder, which also happens to be among one of the differential diagnoses of the disorder.
It is also important to distinguish the diagnosis of Social (Pragmatic) Communication Disorder from language impairments and other developmental or behavioral problems including, but not limited to, ADHD (Attention-Deficit/Hyperactivity Disorder), schizophrenia, and bipolar disorders.
The diagnostic process is likely to involve thorough clinical assessment, with screening questions based on diagnostic criteria. Inputs may be taken from caregivers, parents, and teachers, and structural observations may also be made.
Certain measures to evaluate pragmatic ability are available, which may aid the process. These include the Direct assessment Test of Pragmatic Language (Phelps-Terasaki and Phelps-Gunn, 1992), Pragmatic Rating Scale (Landa, 1992),
Comprehensive Assessment of Spoken Language (Carrow-Woolfolk, 1999), Childrenโs Communication Checklist (Bishop, 2003), The Pragmatics Profile of Everyday Communication Skills in Children (Dewart and Summers, 1995), Language Use Inventory (OโNeill, 2002), and Pragmatic Protocol (Prutting and Kirchner, 1987).
The DSM-5 includes the following diagnostic criteria for Social (Pragmatic) Communication Disorder:
Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:
- 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).
- The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.
- The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities).
- The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder.
Treatment
The treatment of Social (Pragmatic) Communication Disorder is largely based in therapeutic intervention, aiming for outcomes that show improved social communication leading to an improved ability to foster social connections and interpersonal relationships. While there is a lack of conclusive data with regards to the efficacy of various therapeutic modalities, speech therapy is considered to be effective.
Individualized intervention incorporating assistance in developing social understanding and interaction, verbal and non-verbal social communication skills, and language processing skills, has proven effective in trials. Through the aforementioned broad aspects, the intervention aimed to improve conversational and narrative inferential, and world knowledge-based skills.
It is important to consider that it is less likely for treatment intervention for Social (Pragmatic) Communication Disorder to make a lasting change, and long-term assistance is possibly required in order to adjust.
Differential Diagnosis
Autism spectrum disorder: The two disorders can be differentiated by the presence in autism spectrum disorder of restricted/repetitive patterns of behavior, interests, or activities and their absence in social (pragmatic) communication disorder.
Attention-deficit/hyperactivity disorder: Primary features of ADHD may cause impairments in social communication and functional limitations of effective communication, social participation, or academic achievement.
Intellectual disability and global developmental delay: Social communication skills may be deficient among individuals with global developmental delay or intellectual disability, but a separate diagnosis is not given unless the social communication deficits are clearly in excess of the intellectual limitations.
Social anxiety disorder: The symptoms of social communication disorder overlap with those of social anxiety disorder. The differentiating feature is the timing of the onset of symptoms.
Specialist
A psychiatrist or a clinical psychologist is likely to be involved in initial assessment and diagnosis of the disorder, and may be referred by a pediatrician after the realization of inadequate language development in accordance with age-appropriate developmental milestones. A speech therapist may be involved in treatment intervention.
